23 Apr 2025 Lorraine Parker · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 8 Delays in escalation of concerns View source Failure to adequately address concerns about a surgeon across relevant areas View source Unreliable collation and provision of medical and clinical governance records View source Lack of timely scrutiny of unnatural-death cases reported to the coroner View source Lack of records of concerns identified at morbidity and mortality or clinical governance meetings View source Failure of the death investigation process View source Delays in morbidity and mortality meetings View source Poor or defensive structured judgement reviews View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 12
Action
Disseminate clinical governance learning through specialty teams, governance leads, mortality surveillance and Trust committees.
Stated completedThe respondent said that this action was complete when they made their response on 24 April 2025. View source
Action
Collect bariatric and colorectal resection data and present quarterly subspecialty performance indicators for earlier oversight of complications.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 April 2025. View source
Action
Restructure General Surgery morbidity and mortality reviews to include SJR and PSIRF learning, consultant-led contemporaneous records, escalation of unresolved issues and wider dissemination.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 April 2025. View source
Action
Restrict the surgeon’s scope of practice and remove access to various high-risk procedures to support safe practice.
Stated completedThe respondent said that this action was complete when they made their response on 24 April 2025. View source
Action
Introduce a parallel anaesthetist-led SJR to add an independent anaesthetic perspective and identify learning.
Stated completedThe respondent said that this action was complete when they made their response on 24 April 2025. View source
Action
Undertake an in-depth local audit of the surgeon’s practice and identify an increased complication rate.
Stated completedThe respondent said that this action was complete when they made their response on 24 April 2025. View source
Action
Store clinical governance discussion notes on a shared drive and provide Legal Services access for future court disclosures.
Stated plannedThe respondent said that this action was planned when they made their response on 24 April 2025. View source
Action
Introduce structured forms and meeting documentation to capture concerns, learning, recommendations and actions from morbidity and mortality reviews.
Stated completedThe respondent said that this action was complete when they made their response on 24 April 2025. View source
Action
Provide a summary overview with disclosed records covering the clinical timeline, reviews, learning, actions, preventability concerns and review status.
Stated plannedThe respondent said that this action was planned when they made their response on 24 April 2025. View source
Action
Implement an inquest disclosure checklist with required-record checks and scheduled 28-day and 14-day pre-inquest reviews.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 April 2025. View source
Action
Change General Surgery SJR allocation so a subspecialist conducts the review and a second, preferably external-subspecialty, surgeon reviews and signs it.
Stated completedThe respondent said that this action was complete when they made their response on 24 April 2025. View source
Action
Update medical-record disclosure bundles with indexed sections, system-specific records, pagination and cover pages.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 April 2025. View source See 9 more actions
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AI-generated summary
Lorraine Parker · 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
Lorraine Parker died on 30 March 2024 after surgery conducted on 23 January 2024; the inquest recorded that her death involved cancer, necessary surgical treatment, and delay in diagnosing and managing an anastomotic leak. The report raises concerns about the Royal Berkshire Hospital’s death investigation processes, including delayed meetings and escalation, poor or defensive structured judgement reviews, unreliable records, and insufficient scrutiny of cases reported to the coroner.
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 Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in escalation of concerns
Wider context from the report “4. There is delayed escalation of concerns .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately address concerns about a surgeon across relevant areas
Wider context from the report “8. I am concerned about whether the trust has done enough to deal with the concerns about this particular surgeon , not just in the Berkshire area, but more widely .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unreliable collation and provision of medical and clinical governance records
Wider context from the report “7. Systems of collating and providing medical records and clinical governance records to the coroner (and presumably to others involved in death investigation) are unreliable .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of timely scrutiny of unnatural-death cases reported to the coroner
Wider context from the report “6. Delayed or no scrutiny of cases being reported to the coroner because the cause of death is unnatural , given that medical examiners are not funded to scrutinise those cases . Opportunities for early learning are therefore being lost.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of records of concerns identified at morbidity and mortality or clinical governance meetings
Wider context from the report “3. There is little (if any) record of areas of concern identified at meetings – whether at morbidity and mortality meetings or clinical governance meetings .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the death investigation process
Wider context from the report “1. On the evidence I have seen from the three inquests referred to, the Royal Berkshire Hospital’s death investigation process is not working well .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in morbidity and mortality meetings
Wider context from the report “2. I have seen evidence of delayed morbidity and mortality meetings with no clear system for ensuring that these discussions happen timelyously .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor or defensive structured judgement reviews
Wider context from the report “5. Structured judgement reviews I have reviewed are at best, poor, and at worst, defensive .
” 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 Disseminate clinical governance learning through specialty teams, governance leads, mortality surveillance and Trust committees.
Verbatim wording from the response “It has been recognised through this inquest process that there are some specialties where there has been a need to support strengthened learning and we can report that this additional support has already been deployed. With regard to meaningful engagement in processes, and how informed discussions and identified learning are captured in clinical governance minutes, senior members of the Trust’s Quality Governance Team have been attending surgery clinical governance meetings to support the learning and have seen evidence of adoption of Trust processes. These meetings, attended by senior surgical consultants, resident (trainee) doctors and other members of the multi-disciplinary team ensuring learning is cascaded throughout the team. Key learning has also been shared with other Specialty Clinical Governance Leads, the Mortality Surveillance Group and other key Trust committees.” Source location Response from Royal Berkshire NHS Foundation Trust
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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 Collect bariatric and colorectal resection data and present quarterly subspecialty performance indicators for earlier oversight of complications.
Verbatim wording from the response “General Surgery has appointed a departmental mortality lead and a patient safety lead, in addition to the current Clinical Governance lead. As well as their role within the department, these clinical roles will allow specific surgical attendance at Trust Mortality Surveillance and Patient Safety Committees. The consultants will all keep a contemporaneous record of data relating to bariatric and colorectal resections and from this data will have quarterly presentations of key performance indicators relating to each subspecialty. This will allow earlier oversight of significant complications for a particular operation or a particular surgeon. As with all concerns, the Trust has an open culture policy, that should another member of staff have any concerns regarding performance or conduct, they can raise” Source location Response from Royal Berkshire NHS Foundation Trust
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 Restructure General Surgery morbidity and mortality reviews to include SJR and PSIRF learning, consultant-led contemporaneous records, escalation of unresolved issues and wider dissemination.
Verbatim wording from the response “The specialty is now using the M&M slides (Appendix 2) to capture learning and highlight areas of concerns. Examples are given in Appendix 3 of this. Any challenging areas requiring further discussion will be brought to the next consultant meeting to allow time for full exploration, and the learning brought back to the following governance for dissemination. The documenting and contemporaneous note-taking of these discussions will be by the consultant body. The M&M process within the specialty is currently being restructured to ensure learning points from Structured Judgement Reviews (SJRs)” Source location Response from Royal Berkshire NHS Foundation Trust
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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 Restrict the surgeon’s scope of practice and remove access to various high-risk procedures to support safe practice.
Verbatim wording from the response “When the concern regarding a potential increased complication rate came to light an in-depth local audit of practice was undertaken by the Trust. This did indeed identify that the surgeon had a higher complication rate than his peers. Following this, a mutual decision was taken to limit the surgeon’s scope of practice whilst a further investigation was conducted. This investigation was conducted in line with the Trust’s “Maintaining High Professional Standards (MHPS)” policy and encompassed four” Source location Response from Royal Berkshire NHS Foundation Trust
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 Introduce a parallel anaesthetist-led SJR to add an independent anaesthetic perspective and identify learning.
Verbatim wording from the response “We have also introduced a parallel anaesthetist led SJR to strengthen the review and identify learning, in recognition of the different perspectives that surgeons and anaesthetists can bring to the same case.” Source location Response from Royal Berkshire NHS Foundation Trust
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 Undertake an in-depth local audit of the surgeon’s practice and identify an increased complication rate.
Verbatim wording from the response “When the concern regarding a potential increased complication rate came to light an in-depth local audit of practice was undertaken by the Trust. This did indeed identify that the surgeon had a higher complication rate than his peers. Following this, a mutual decision was taken to limit the surgeon’s scope of practice whilst a further investigation was conducted. This investigation was conducted in line with the Trust’s “Maintaining High Professional Standards (MHPS)” policy and encompassed four” Source location Response from Royal Berkshire NHS Foundation Trust
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 Store clinical governance discussion notes on a shared drive and provide Legal Services access for future court disclosures.
Verbatim wording from the response “The Trust acknowledges HM Coroner’s concerns that some of these reflections and notes of discussions are not provided timeously to the coroner. The Trust confirms the notes of these discussions will be stored on shared clinical governance drive and the Trust will provide access to the Legal Services Team to these notes so that in future they are available when disclosing medical records to the court. To assist with this, we are developing a checklist of items which may be required for inquests, along with how to locate them on the Trust’s systems.” Source location Response from Royal Berkshire NHS Foundation Trust
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 Introduce structured forms and meeting documentation to capture concerns, learning, recommendations and actions from morbidity and mortality reviews.
Verbatim wording from the response “Morbidity and mortality meetings are undertaken in each specialty where a death happens as part of specialty clinical governance processes. A systematic way for teams to capture learning is in place and set out below. The Trust also attaches Appendix 2, a set of forms to support the review process, designed to highlight any issues that may have arisen in care, together with a means of recording any recommendations and actions. This process is well established for specialties including intensive care and renal medicine and has been introduced into M&M meetings for general surgery from May 2025 with the learning captured within the clinical governance minutes. Specialty clinical governance minutes are disseminated to specialty team members by email as well as to the governance team and stored on a Trust shared drive where all specialty clinical governance minutes are held.” Source location Response from Royal Berkshire NHS Foundation Trust
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 Provide a summary overview with disclosed records covering the clinical timeline, reviews, learning, actions, preventability concerns and review status.
Verbatim wording from the response “The Trust recognises there is a need for greater clarity of learning and actions undertaken for a case especially where there have been multiple types of review. Our intention is to provide a summary overview of the case with the notes disclosure (Appendix 4). This will include a brief factual timeline of the patient’s clinical journey, key diagnoses and treatment and circumstances of deterioration and death. The next section will include the Trust reviews undertaken, each with a concise summary of learning points, and outline of actions taken by the Trust including communications with the family. The Trust will identify any concerns around avoidability and preventability. The Trust will be clear whether all reviews are now complete and if any are ongoing. The latter recognises that additional reviews are on occasion indicated if new learning or information becomes available.” Source location Response from Royal Berkshire NHS Foundation Trust
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 Implement an inquest disclosure checklist with required-record checks and scheduled 28-day and 14-day pre-inquest reviews.
Verbatim wording from the response “The Trust acknowledges HM Coroner’s concerns that some of these reflections and notes of discussions are not provided timeously to the coroner. The Trust confirms the notes of these discussions will be stored on shared clinical governance drive and the Trust will provide access to the Legal Services Team to these notes so that in future they are available when disclosing medical records to the court. To assist with this, we are developing a checklist of items which may be required for inquests, along with how to locate them on the Trust’s systems.” Source location Response from Royal Berkshire NHS Foundation Trust
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 Change General Surgery SJR allocation so a subspecialist conducts the review and a second, preferably external-subspecialty, surgeon reviews and signs it.
Verbatim wording from the response “General surgery have made changes to how structured judgement reviews are performed. Historically, cases were allocated to an individual GI surgeon, who may not have had the same subspecialist interest (e.g. colorectal surgery, upper GI surgery, and bariatric surgery) as the particular case being examined. It has been agreed that moving forward the SJR will be performed by a person with the same subspecialist interest, with and then reviewed by a second surgeon, preferably from outside that subspecialty. Both surgeons will sign off on this and have their name attached to the report. This subspecialty engagement and sense checking of reviews should provide a robust approach with more thoughtful outcomes.” Source location Response from Royal Berkshire NHS Foundation Trust
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 Update medical-record disclosure bundles with indexed sections, system-specific records, pagination and cover pages.
Verbatim wording from the response “b. Formatting of records disclosed” Source location Response from Royal Berkshire NHS Foundation Trust
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 Trust considers it has taken all necessary, proportionate and reasonable steps to escalate and manage concerns about the surgeon.
Verbatim wording from the response “restriction to practice was agreed with the surgeon, the Trust RO made contact with the RO at the local private hospital that the surgeon was also practising at. As far as the Trust is aware, similar restrictions to the surgeon’s scope of practice were implemented there too and the RO is being kept informed of the Trust’s investigation and processes. To the Trust’s knowledge the surgeon does not undertake medical practice at any other providers.” Source location Response from Royal Berkshire NHS Foundation Trust
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 Trust considers its established death investigation processes robust and sufficient to underpin learning and patient safety.
Verbatim wording from the response “1. On the evidence I have seen from the three inquests referred to, the Royal Berkshire Hospital’s death investigation process is not working well.” Source location Response from Royal Berkshire NHS Foundation Trust
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 Trust did not repeat one Structured Judgement Review because a more detailed investigation and inquest evidence superseded that review.
Verbatim wording from the response “The mortality team were aware that the SJR 1s for ME and MR both done by upper GI surgeons and not the colorectal surgeons, were not sufficiently thorough or enough of a considered review by general surgery. The completion did not meet the standard expected in relation to this process.” Source location Response from Royal Berkshire NHS Foundation Trust
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 All three cases received timely, proportionate Medical Examiner scrutiny and appropriate referral or Trust review, so early learning was not lost.
Verbatim wording from the response “6. Delayed or no scrutiny of cases being reported to the coroner because the cause of death is unnatural, given that medical examiners are not funded to scrutinise those cases. Opportunities for early learning are therefore being lost.” Source location Response from Royal Berkshire NHS Foundation Trust
Open published response
16 Aug 2023 Devon Drew Turner · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 7 Failure to ensure that SATS machines are suitable and easy to use at home View source Failure to train parents to use the particular SATS machine brand issued View source Failure of SATS machine alarm volume to wake sleeping parents View source Failure to ensure the reliability of SATS machines sent home with vulnerable patients View source Failure of SATS machine alarms to sound reliably View source Failure to provide accurate SATS machine event data and analysis View source Failure of SATS machine alarms to remain active or sound when required View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Devon Drew Turner · 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
Devon Drew Turner, who had Mosaic Trisomy 9 and significant respiratory vulnerability, died at hospital on 10 May 2022 after being found unresponsive at home. The report raises concerns about the reliability, suitability, alarm function and data recording of SATS monitoring machines provided for use by vulnerable babies at home, including whether parents were adequately trained on the particular device supplied.
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 Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that SATS machines are suitable and easy to use at home
Wider context from the report “Matter of Concern 1:
3. On 25 April 2022 this second SATS machine, stopped working. It had some sort of error message on the screen. The parents contacted the community nurse team and Devon’s mother had to attend the hospital that night to pick up a new SATS machine.
4. Therefore the first concern is regarding the reliability of such SATS machines sent home with vulnerable patients.
5. If a safety plan is put in place which includes the use of a SATS machine to monitor the wellbeing of the patient, and that machine is less than at least 99% reliable, or has software issues, or is unsuitable for home use, or is complicated to use , this may result in a false sense of security from the family who will rely on the machine to alert them if the oxygen levels drop below a certain figure.
6. Therefore there is a risk that future deaths will occur if hospital trusts do not ensure that the SATS machines are reliable and easy to use and that parents are trained to use the particular brand they are issued with.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to train parents to use the particular SATS machine brand issued
Wider context from the report “Matter of Concern 1:
3. On 25 April 2022 this second SATS machine, stopped working. It had some sort of error message on the screen. The parents contacted the community nurse team and Devon’s mother had to attend the hospital that night to pick up a new SATS machine.
4. Therefore the first concern is regarding the reliability of such SATS machines sent home with vulnerable patients.
5. If a safety plan is put in place which includes the use of a SATS machine to monitor the wellbeing of the patient, and that machine is less than at least 99% reliable, or has software issues, or is unsuitable for home use, or is complicated to use, this may result in a false sense of security from the family who will rely on the machine to alert them if the oxygen levels drop below a certain figure.
6. Therefore there is a risk that future deaths will occur if hospital trusts do not ensure that the SATS machines are reliable and easy to use and that parents are trained to use the particular brand they are issued with .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of SATS machine alarm volume to wake sleeping parents
Wider context from the report “Matter of Concern 2:
8. The third machine was issued to the family on 25 April 2022, which remained with them until Devon’s death. It was manufactured by Medtronic (Model number MBB1920904). It is not known if this was the same brand as the second SATS machine mentioned above.
9. The concern is that this Medtronic machine was also either not functioning reliably or was not suitable for the home environment.
10. On 10 May 2022 Devon was given his 1am feed and the family settled down to sleep. At 4.30am Devon’s mother woke to find him unresponsive. The CPAP machine log confirms those two times.
11. The SATS machine was seized by the police on 10 May 2022.
12. Medtronic technician, ████████ made a statement dated 6/7/2022 which I append to this Report, in which he states that:
• The testing of the SATS machine revealed that it was functioning properly
• The data from the machine shows that from approximately 1.44am Devon’s oxygen saturations started to drop and continued to fall until approximately 2.00am when there was no pulse.
• The alarm would have been sounding throughout that time and that at the loss of pulse, at 2.00am a further alarm would have sounded.
• The machine alarm was at maximum volume
• There is a silence button on the machine but that it only silences the alarm for 60 seconds, after which interval the alarm would sound again throughout the whole period that the saturation levels were low.
13. Given the crucial role a SATS machine has in monitoring a vulnerable baby at home, with non-medically trained carers who need to sleep, there should be no doubt but that the alarm sound will sound reliably, that its volume will wake sleeping exhausted parents and should provide an accurate log of events.
14. The conclusions that the data from the SATS machine appear to provide do not accord with the other evidence provided to the inquest about the events in question. That gives cause for concern that either the analysis of the SATS machine has not been accurate or the SATS machine has not correctly recorded the data or that this SATS machine is not a suitable device for use at home.
15. For example, the community nurses would have noticed if the SATS machine was not working in the first weeks of Devon being at home and yet it has recorded that it was not used at all until 31 May 2022.
16. Secondly in order for the SATS machine data to have been correct about events of 10 May 2022, either both the parents would have had to sleep through an alarm sounding for at least 15 minutes at full volume as well as a second alarm after 15 minutes at the loss of pulse, or the parents would have had to have used the silence button on the alarm system every 60 seconds for that 15 minute period.
17. The SATS machine silence button was not within reach of Devon’s mother unless she sat up and reached up and over baby Devon in his cot. Devon’s father would have had to get out of bed altogether. A copy of the police photographs of the bedroom on 10 May 2022 is attached to this report. It is inconceivable that these concerned and careful parents, who had taken such an active role in Devon’s care, would have turned off this alarm in this way several times and failed to notice his respiratory distress, and when he was found unresponsive, would have forgotten that they had silenced the alarm in this way. Therefore either the SATS machine did not function as it should or was not sufficiently loud to wake either of these careful parents.
18. The potential for future deaths is that future parents will also rely on the SATS machine to alert them to a vulnerable child stopping breathing and taking action will not be alerted because either the alarm is too quiet , or it cuts out automatically before waking the parents, or it simply does not sound 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 Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure the reliability of SATS machines sent home with vulnerable patients
Wider context from the report “Matter of Concern 1:
3. On 25 April 2022 this second SATS machine, stopped working. It had some sort of error message on the screen. The parents contacted the community nurse team and Devon’s mother had to attend the hospital that night to pick up a new SATS machine.
4. Therefore the first concern is regarding the reliability of such SATS machines sent home with vulnerable patients .
5. If a safety plan is put in place which includes the use of a SATS machine to monitor the wellbeing of the patient, and that machine is less than at least 99% reliable , or has software issues, or is unsuitable for home use, or is complicated to use, this may result in a false sense of security from the family who will rely on the machine to alert them if the oxygen levels drop below a certain figure.
6. Therefore there is a risk that future deaths will occur if hospital trusts do not ensure that the SATS machines are reliable and easy to use and that parents are trained to use the particular brand they are issued with.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of SATS machine alarms to sound reliably
Wider context from the report “Matter of Concern 2:
8. The third machine was issued to the family on 25 April 2022, which remained with them until Devon’s death. It was manufactured by Medtronic (Model number MBB1920904). It is not known if this was the same brand as the second SATS machine mentioned above.
9. The concern is that this Medtronic machine was also either not functioning reliably or was not suitable for the home environment.
10. On 10 May 2022 Devon was given his 1am feed and the family settled down to sleep. At 4.30am Devon’s mother woke to find him unresponsive. The CPAP machine log confirms those two times.
11. The SATS machine was seized by the police on 10 May 2022.
12. Medtronic technician, ████████ made a statement dated 6/7/2022 which I append to this Report, in which he states that:
• The testing of the SATS machine revealed that it was functioning properly
• The data from the machine shows that from approximately 1.44am Devon’s oxygen saturations started to drop and continued to fall until approximately 2.00am when there was no pulse.
• The alarm would have been sounding throughout that time and that at the loss of pulse, at 2.00am a further alarm would have sounded.
• The machine alarm was at maximum volume
• There is a silence button on the machine but that it only silences the alarm for 60 seconds, after which interval the alarm would sound again throughout the whole period that the saturation levels were low.
13. Given the crucial role a SATS machine has in monitoring a vulnerable baby at home, with non-medically trained carers who need to sleep, there should be no doubt but that the alarm sound will sound reliably , that its volume will wake sleeping exhausted parents and should provide an accurate log of events.
14. The conclusions that the data from the SATS machine appear to provide do not accord with the other evidence provided to the inquest about the events in question. That gives cause for concern that either the analysis of the SATS machine has not been accurate or the SATS machine has not correctly recorded the data or that this SATS machine is not a suitable device for use at home.
15. For example, the community nurses would have noticed if the SATS machine was not working in the first weeks of Devon being at home and yet it has recorded that it was not used at all until 31 May 2022.
16. Secondly in order for the SATS machine data to have been correct about events of 10 May 2022, either both the parents would have had to sleep through an alarm sounding for at least 15 minutes at full volume as well as a second alarm after 15 minutes at the loss of pulse, or the parents would have had to have used the silence button on the alarm system every 60 seconds for that 15 minute period.
17. The SATS machine silence button was not within reach of Devon’s mother unless she sat up and reached up and over baby Devon in his cot. Devon’s father would have had to get out of bed altogether. A copy of the police photographs of the bedroom on 10 May 2022 is attached to this report. It is inconceivable that these concerned and careful parents, who had taken such an active role in Devon’s care, would have turned off this alarm in this way several times and failed to notice his respiratory distress, and when he was found unresponsive, would have forgotten that they had silenced the alarm in this way. Therefore either the SATS machine did not function as it should or was not sufficiently loud to wake either of these careful parents.
18. The potential for future deaths is that future parents will also rely on the SATS machine to alert them to a vulnerable child stopping breathing and taking action will not be alerted because either the alarm is too quiet, or it cuts out automatically before waking the parents, or it simply does not sound 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 Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate SATS machine event data and analysis
Wider context from the report “Matter of Concern 2:
8. The third machine was issued to the family on 25 April 2022, which remained with them until Devon’s death. It was manufactured by Medtronic (Model number MBB1920904). It is not known if this was the same brand as the second SATS machine mentioned above.
9. The concern is that this Medtronic machine was also either not functioning reliably or was not suitable for the home environment.
10. On 10 May 2022 Devon was given his 1am feed and the family settled down to sleep. At 4.30am Devon’s mother woke to find him unresponsive. The CPAP machine log confirms those two times.
11. The SATS machine was seized by the police on 10 May 2022.
12. Medtronic technician, ████████ made a statement dated 6/7/2022 which I append to this Report, in which he states that:
• The testing of the SATS machine revealed that it was functioning properly
• The data from the machine shows that from approximately 1.44am Devon’s oxygen saturations started to drop and continued to fall until approximately 2.00am when there was no pulse.
• The alarm would have been sounding throughout that time and that at the loss of pulse, at 2.00am a further alarm would have sounded.
• The machine alarm was at maximum volume
• There is a silence button on the machine but that it only silences the alarm for 60 seconds, after which interval the alarm would sound again throughout the whole period that the saturation levels were low.
13. Given the crucial role a SATS machine has in monitoring a vulnerable baby at home, with non-medically trained carers who need to sleep, there should be no doubt but that the alarm sound will sound reliably, that its volume will wake sleeping exhausted parents and should provide an accurate log of events .
14. The conclusions that the data from the SATS machine appear to provide do not accord with the other evidence provided to the inquest about the events in question. That gives cause for concern that either the analysis of the SATS machine has not been accurate or the SATS machine has not correctly recorded the data or that this SATS machine is not a suitable device for use at home.
15. For example, the community nurses would have noticed if the SATS machine was not working in the first weeks of Devon being at home and yet it has recorded that it was not used at all until 31 May 2022.
16. Secondly in order for the SATS machine data to have been correct about events of 10 May 2022, either both the parents would have had to sleep through an alarm sounding for at least 15 minutes at full volume as well as a second alarm after 15 minutes at the loss of pulse, or the parents would have had to have used the silence button on the alarm system every 60 seconds for that 15 minute period.
17. The SATS machine silence button was not within reach of Devon’s mother unless she sat up and reached up and over baby Devon in his cot. Devon’s father would have had to get out of bed altogether. A copy of the police photographs of the bedroom on 10 May 2022 is attached to this report. It is inconceivable that these concerned and careful parents, who had taken such an active role in Devon’s care, would have turned off this alarm in this way several times and failed to notice his respiratory distress, and when he was found unresponsive, would have forgotten that they had silenced the alarm in this way. Therefore either the SATS machine did not function as it should or was not sufficiently loud to wake either of these careful parents.
18. The potential for future deaths is that future parents will also rely on the SATS machine to alert them to a vulnerable child stopping breathing and taking action will not be alerted because either the alarm is too quiet, or it cuts out automatically before waking the parents, or it simply does not sound 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 Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of SATS machine alarms to remain active or sound when required
Wider context from the report “Matter of Concern 2:
8. The third machine was issued to the family on 25 April 2022, which remained with them until Devon’s death. It was manufactured by Medtronic (Model number MBB1920904). It is not known if this was the same brand as the second SATS machine mentioned above.
9. The concern is that this Medtronic machine was also either not functioning reliably or was not suitable for the home environment.
10. On 10 May 2022 Devon was given his 1am feed and the family settled down to sleep. At 4.30am Devon’s mother woke to find him unresponsive. The CPAP machine log confirms those two times.
11. The SATS machine was seized by the police on 10 May 2022.
12. Medtronic technician, ████████ made a statement dated 6/7/2022 which I append to this Report, in which he states that:
• The testing of the SATS machine revealed that it was functioning properly
• The data from the machine shows that from approximately 1.44am Devon’s oxygen saturations started to drop and continued to fall until approximately 2.00am when there was no pulse.
• The alarm would have been sounding throughout that time and that at the loss of pulse, at 2.00am a further alarm would have sounded.
• The machine alarm was at maximum volume
• There is a silence button on the machine but that it only silences the alarm for 60 seconds, after which interval the alarm would sound again throughout the whole period that the saturation levels were low.
13. Given the crucial role a SATS machine has in monitoring a vulnerable baby at home, with non-medically trained carers who need to sleep, there should be no doubt but that the alarm sound will sound reliably, that its volume will wake sleeping exhausted parents and should provide an accurate log of events.
14. The conclusions that the data from the SATS machine appear to provide do not accord with the other evidence provided to the inquest about the events in question. That gives cause for concern that either the analysis of the SATS machine has not been accurate or the SATS machine has not correctly recorded the data or that this SATS machine is not a suitable device for use at home.
15. For example, the community nurses would have noticed if the SATS machine was not working in the first weeks of Devon being at home and yet it has recorded that it was not used at all until 31 May 2022.
16. Secondly in order for the SATS machine data to have been correct about events of 10 May 2022, either both the parents would have had to sleep through an alarm sounding for at least 15 minutes at full volume as well as a second alarm after 15 minutes at the loss of pulse, or the parents would have had to have used the silence button on the alarm system every 60 seconds for that 15 minute period.
17. The SATS machine silence button was not within reach of Devon’s mother unless she sat up and reached up and over baby Devon in his cot. Devon’s father would have had to get out of bed altogether. A copy of the police photographs of the bedroom on 10 May 2022 is attached to this report. It is inconceivable that these concerned and careful parents, who had taken such an active role in Devon’s care, would have turned off this alarm in this way several times and failed to notice his respiratory distress, and when he was found unresponsive, would have forgotten that they had silenced the alarm in this way. Therefore either the SATS machine did not function as it should or was not sufficiently loud to wake either of these careful parents.
18. The potential for future deaths is that future parents will also rely on the SATS machine to alert them to a vulnerable child stopping breathing and taking action will not be alerted because either the alarm is too quiet, or it cuts out automatically before waking the parents, or it simply does not sound at all .
” Open source report
15 Feb 2023 Raniya Rizwan Khan · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 5 Failure to refer concerns about an agency midwife to the Nursing and Midwifery Council View source Failure to train staff on placenta retention procedures View source Failure to maintain the system for communicating relevant paediatric admissions and deterioration to maternity staff View source Failure to refer concerns about an agency midwife to NHS Professionals View source Absence of a standard operating procedure for placenta retention View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Raniya Rizwan Khan · 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
Raniya Rizwan Khan was born on 9 May 2020 and died at Great Ormond Street Hospital on 28 May 2020 after her condition deteriorated; the recorded cause of death was multi-organ failure and severe arterial pulmonary hypertension of unknown cause. Concerns included failures in labour monitoring and escalation by an agency midwife, and the reported non-completion of trust undertakings concerning placenta retention, related procedures and staff training.
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 Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer concerns about an agency midwife to the Nursing and Midwifery Council
Wider context from the report “I was also advised that there has been no approach made to NHS Professionals about concerns with the midwife in question. Similarly, no approach to the NMC has been made .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to train staff on placenta retention procedures
Wider context from the report “It was surprising in the extreme to be made aware in open court on the final day of this inquest that these undertakings have not in fact been completed – the system referred to above is not in place, there is no SOP, nor has there been any staff training . It was particularly disappointing to hear this in front of a family who had themselves lost a baby and who were being reassured of how committed the trust is to improvement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain the system for communicating relevant paediatric admissions and deterioration to maternity staff
Wider context from the report “It was surprising in the extreme to be made aware in open court on the final day of this inquest that these undertakings have not in fact been completed – the system referred to above is not in place , there is no SOP, nor has there been any staff training. It was particularly disappointing to hear this in front of a family who had themselves lost a baby and who were being reassured of how committed the trust is to improvement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer concerns about an agency midwife to NHS Professionals
Wider context from the report “I was also advised that there has been no approach made to NHS Professionals about concerns with the midwife in question . Similarly, no approach to the NMC has been made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a standard operating procedure for placenta retention
Wider context from the report “It was surprising in the extreme to be made aware in open court on the final day of this inquest that these undertakings have not in fact been completed – the system referred to above is not in place, there is no SOP , nor has there been any staff training. It was particularly disappointing to hear this in front of a family who had themselves lost a baby and who were being reassured of how committed the trust is to improvement.
” Open source report
20 Jun 2022 Adele Angel Massoudi · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 3 Failure to retain placentas when required for death investigation View source Insufficient midwifery training on prioritising emergency ambulance calls View source Failure to prioritise calling an ambulance during a home birth emergency 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
Adele Angel Massoudi · 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
Adele Angel Massoudi was born at home on 26 June 2020, transferred to hospital, and died there on 2 July 2020; the recorded cause of death was severe hypoxic ischaemic encephalopathy. The report identified delays in responding to meconium, inadequate fetal heart-rate monitoring, delayed transfer to hospital, inadequate communication with the family, and destruction of the placenta without retaining it for examination. Concerns focused on midwifery training and the retention of placentas for death investigation.
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 Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain placentas when required for death investigation
Wider context from the report “In terms of learning from these cases, examination of the placenta, either as part of a formal autopsy, or even without an autopsy, is absolutely vital. It is akin to asking a pathologist to
conduct a post-mortem examination without one of the organs, if the placenta is not retained.
I am concerned about the response from the hospital trust on this point. I am told that the guideline for placenta examination is being reviewed and I quote from the statement sent by the Director of Midwifery, dated 6 June 2022:
We continue to explore opportunities that may extend placental storage.
It does not go far enough simply to state “we are looking into it” at this stage, or that the trust does not have the space to store placentas for longer. I appreciate that the Human Tissue Act and other considerations have to be taken into account. It is not insurmountable, and I believe the trust must now be given a deadline for responding to this concern, in the format of a Regulation 28 Report, in order to ensure that a decision has been made. There are cases where keeping the placenta is clearly required - such as this case - because Adele was born in a poor condition. The practical realities have to be taken into account, and a line drawn as to when placentas should be kept for longer than usual. Currently, placentas in uncomplicated cases are being disposed of daily.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient midwifery training on prioritising emergency ambulance calls
Wider context from the report “She accepted in her evidence that it was open to her to ask someone else on scene, including a family member, to call for an ambulance. I remain concerned that the response of the key witness appears to be “I did what I could in difficult circumstances, and I had a lot to do”. The situation that the midwife was dealing with must indeed have been very stressful, but it is part of a midwife’s professional training to assess what is the most urgent thing to do first. That is not setting up equipment, waiting for contractions to finish et cetera. It is, in this scenario, to call an ambulance first and then do everything else afterwards. I remain concerned that, even after all the additional training, and having had this awful experience, this message is not coming through loud and clear from the witness evidence.
It is difficult to know whether a need for further training exists in relation to this witness, or more systemically. I am concerned that, having experienced this awful tragedy, and going through the HSIB investigation and the inquest process, anything other than full acceptance of the point was offered in evidence. I invite the trust to consider again the training of their midwives and whether the training provided to date is sufficient and safe , and to respond formally and in a Regulation 28 response.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise calling an ambulance during a home birth emergency
Wider context from the report “She accepted in her evidence that it was open to her to ask someone else on scene, including a family member, to call for an ambulance. I remain concerned that the response of the key witness appears to be “I did what I could in difficult circumstances, and I had a lot to do”. The situation that the midwife was dealing with must indeed have been very stressful, but it is part of a midwife’s professional training to assess what is the most urgent thing to do first. That is not setting up equipment, waiting for contractions to finish et cetera. It is, in this scenario, to call an ambulance first and then do everything else afterwards. I remain concerned that, even after all the additional training, and having had this awful experience, this message is not coming through loud and clear from the witness evidence.
It is difficult to know whether a need for further training exists in relation to this witness, or more systemically. I am concerned that, having experienced this awful tragedy, and going through the HSIB investigation and the inquest process, anything other than full acceptance of the point was offered in evidence. I invite the trust to consider again the training of their midwives and whether the training provided to date is sufficient and safe, and to respond formally and in a Regulation 28 response.
” Open source report
15 Jul 2014 Stephen Peter Church · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 4 Lack of joint working to address high self-harm risk promptly View source Insufficient knowledge and understanding of the interagency mental health working protocol View source Breakdown of the British Transport Police chain of command for detention responsibilities View source Lack of appreciation of the need to contact an approved mental health professional promptly for a Mental Health Act assessment 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
Stephen Peter Church · 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
Stephen Church was found dead at the entrance to the multi-storey car park at Royal Berkshire Hospital on 13 May 2011 after absconding while detained under section 136 of the Mental Health Act 1983. The concerns included a broken chain of command resulting in only one police officer being responsible for his detention, insufficient understanding of an interagency working protocol, inadequate joint working to keep him safe, and delay in contacting an approved mental health professional to arrange a Mental Health Act assessment.
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 Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of joint working to address high self-harm risk promptly
Wider context from the report “(3) There was a lack of joint working amongst the British Transport Police, Royal Berkshire Hospital and psychiatric liaison service staff members to ensure that Stephen Church was safe and the high risk of him self-harming addressed promptly .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient knowledge and understanding of the interagency mental health working protocol
Wider context from the report “(2) There was insufficient knowledge and understanding amongst members of the psychiatric liaison service and the Royal Berkshire Hospital as regards the "Interagency joint Working Protocol for the Management of Mental Health Thames Valley 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 Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Breakdown of the British Transport Police chain of command for detention responsibilities
Wider context from the report “(1) The chain of command within the British Transport Police was broken unacceptably leading to only one police officer responsible for detaining Mr Church .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Berkshire NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appreciation of the need to contact an approved mental health professional promptly for a Mental Health Act assessment
Wider context from the report “There was a lack of appreciation amongst the psychiatric liaison service, Royal Berkshire Hospital staff and British Transport Police as to the importance of contacting an approved mental health professional promptly to arrange a Mental Health Act assessment .
” 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 Disseminate the revised protocol to senior staff and crisis-care personnel across participating agencies.
Verbatim wording from the response “1. In relation to the concern that there was insufficient knowledge and understanding amongst members of the Psychiatric Liaison Service and the Royal Berkshire Hospital with regards the interagency working protocol for the management of mental health in the Thames Valley area, an interagency meeting was held on 24 September 2014 to identify the gaps in the various agencies’ knowledge and understanding with a plan put in place to revise the current protocol and to hold a consultation. The protocol will be sent to all senior staff involved in crisis management of these patients and there will be training in the use of the protocol for all of the agencies.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Hold interagency meetings to identify knowledge gaps and improve joint working on Section 136 patient care.
Verbatim wording from the response “The meeting was held to discuss the concerns raised by the coroner. With regards the first area of concern, this was within the control of the British Transport Police and so we did not discuss it in any depth. We understand a separate response has been sent.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Consult agencies on the revised interagency Section 136 protocol before requiring participating agencies to sign it.
Verbatim wording from the response “A revised version of the protocol is currently being finalised by Thames Valley Police under the supervision of ████████, Inspector, Thames Valley Police, and Mental Health Lead. ████████, Mental Health Act Administrator, is also assisting with the revision of the protocol. The intention is for the protocol to be clearer and easier to understand/ navigate so that the agencies can work together more effectively and are able to identify their individual roles with regards patients who are admitted to the Trust under Section 136 of the Mental Health Act 1983.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Send completed Section 136 monitoring forms to the Trust’s Mental Health Coordinator so care can be audited.
Verbatim wording from the response “the patient to be assessed with either admission to the Trust with support from PMS or a transfer to a place of safety e.g. Prospect Park Hospital. The flowchart has been finalised and approved by the A&E Clinical Governance Team. The Royal Berkshire NHS Foundation Trust has also adopted the assessment forms for Section 136 monitoring from the mental health Trust so that the key information is gathered on admission and the nursing staff are able to identify whether the AMHP has been informed of the need for assessment at an early stage. There will be a further check made by the PMS who will advise the A&E staff regarding the management of the Section 136 patient in the A&E Department. PMS will also check whether the AMHP has been contacted. Copies of the assessment form for Section 136 will be sent to the RBH Mental Health Coordinator so that care can be audited.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Display the approved Section 136 flowchart prominently in the A&E department.
Verbatim wording from the response “In the meantime, the Royal Berkshire NHS Foundation Trust has finalised and approved a flowchart that will be prominently displayed in the A&E department. It is intended that the flowchart will be in place in the A&E department before 26 November 2014 and that staff will have received training with regards use of the flowchart and the S136 monitoring forms by the end of November 2014.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Provide cross-agency training on using the revised Section 136 protocol, flowchart and monitoring forms.
Verbatim wording from the response “There will also be implementation of a training programme which again will be open to all of the agencies that sign up to the protocol. British Transport Police are unable to sign local protocols because they are a national force but they have agreed to abide by it.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Finalize and approve an A&E flowchart identifying Section 136 admission, AMHP contact and patient-management steps.
Verbatim wording from the response “The flowchart will provide the A&E staff with a clear picture of the questions that they need to ask when the Section 136 patient is admitted, in order to identify the appropriate AMHP so that they can attend as quickly as possible which is not what happened in the case of SC. The contact numbers for the 6 different areas will be included and the Trust will adopt the Section 136 monitoring forms used by the Mental Health Services.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Require senior A&E staff to ensure AMHP contact and use Psychological Medicine Service checks to confirm contact and advise on patient management.
Verbatim wording from the response “2. The trust has a flowchart which identifies the steps that need to be taken from the point of admission to A&E and identifies the role of the psychological medicine service (PMS) at the Trust who will advise A&E on the management of the patient in the A&E Department. They will also check that AMHP has been called which was a particular area of concern.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Adopt Section 136 monitoring forms to capture admission information and whether the AMHP has been contacted.
Verbatim wording from the response “The flowchart will provide the A&E staff with a clear picture of the questions that they need to ask when the Section 136 patient is admitted, in order to identify the appropriate AMHP so that they can attend as quickly as possible which is not what happened in the case of SC. The contact numbers for the 6 different areas will be included and the Trust will adopt the Section 136 monitoring forms used by the Mental Health Services.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 A&E staff retain responsibility for the patient and contacting the AMHP; the Psychological Medicine Service will advise but not assume responsibility.
Verbatim wording from the response “In the meantime, the two senior consultants from the A&E department, ████████ and the Matron ████████ attended the inter-agency meeting at the Trust on 24 September and have taken the message back to the A&E department that they should be liaising with the PMS at the Trust who, although they will not take responsibility for the patient, will advise on their management and contacting the AMHP if that has not already been done. There is therefore a mechanism whereby the A&E staff will be aware that it is their responsibility to check that the AMHP has been contacted and if for any reason it is not done for the PMS to make sure that contact is made at the earliest opportunity.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 Responsibility for the police chain-of-command concern lies with British Transport Police, which is addressing it separately.
Verbatim wording from the response “The meeting was held to discuss the concerns raised by the coroner. With regards the first area of concern, this was within the control of the British Transport Police and so we did not discuss it in any depth. We understand a separate response has been sent.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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 British Transport Police cannot sign local protocols because it is a national force, but has agreed to abide by the protocol.
Verbatim wording from the response “There will also be implementation of a training programme which again will be open to all of the agencies that sign up to the protocol. British Transport Police are unable to sign local protocols because they are a national force but they have agreed to abide by it.” Source location 2014-0331-Response-by-Royal-Berkshire-NHS-Trust1
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations