30 Mar 2026 Ethan Michael Hanson · Prevention of Future Deaths report Warwickshire
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Concerns raised 8 Lack of practical mechanisms for communicating with neurodivergent parents View source Failure of the paediatric abdominal pain pathway to align with GIRFT structure and escalation principles View source Lack of structured local support for interpreting neurodivergent parental communication View source Lack of practical mechanisms for adapting assessment of neurodivergent children View source Lack of structured local prompts for recognising neurodivergent symptom expression View source Failure to carry critical GP information into hospital assessment View source Lack of GP awareness of referral-route implications for local hospital triage and assessment View source Absence of computerised safeguards for complete and accurate observations before pathway selection or discharge View source See 5 more concerns
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AI-generated summary
Ethan Michael Hanson · 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
Ethan was assessed by his GP and then at hospital for abdominal pain, vomiting and concern about appendicitis, but was discharged without senior review after abnormal observations and the GP’s concerns were not transferred to the hospital assessment. He later collapsed, suffered cardiac arrest, and died after imaging confirmed perforated appendicitis, peritonitis and sepsis. The principal concerns include inaccurate or incomplete observations and pain assessment, pathway and escalation arrangements that did not align with guidance, inadequate support for assessing neurodivergent children and parents, and loss of critical information during transfer from primary to hospital care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of practical mechanisms for communicating with neurodivergent parents
Wider context from the report “GIRFT guidance lacks practical mechanisms for assessing neurodivergent children and parents
The GIRFT guidance recognises that neurodivergent children may be more difficult to assess or diagnose, but it does not provide practical mechanisms for clinicians to adapt history-taking, pain assessment or communication. The guidance does not consider the risk that a neurodivergent parent may struggle to convey concern, may appear reassured when they are frightened, or may find questions and instructions confusing or intimidating. The absence of such mechanisms risks misunderstanding children’s symptoms and misinterpreting parental reassurance.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure of the paediatric abdominal pain pathway to align with GIRFT structure and escalation principles
Wider context from the report “Pathway design not fully aligned with national GIRFT guidance
The Trust is developing a triage model for paediatric abdominal pain. Evidence heard at inquest showed that the pathway options do not mirror the structure or escalation principles contained in the national GIRFT guidance for paediatric abdominal pain and appendicitis. This carries a risk that children with time-critical surgical conditions may not be escalated promptly or placed on an appropriate pathway.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of structured local support for interpreting neurodivergent parental communication
Wider context from the report “Local processes provide no structured support for neurodivergent children or parents
Local assessment processes do not contain structured prompts or guidance for recognising how neurodivergence may affect symptom expression or parental communication. Without a structured approach there is a risk that important clinical information will not be elicited or understood, and that apparent agreement with a discharge plan may be misinterpreted.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of practical mechanisms for adapting assessment of neurodivergent children
Wider context from the report “GIRFT guidance lacks practical mechanisms for assessing neurodivergent children and parents
The GIRFT guidance recognises that neurodivergent children may be more difficult to assess or diagnose, but it does not provide practical mechanisms for clinicians to adapt history-taking, pain assessment or communication. The guidance does not consider the risk that a neurodivergent parent may struggle to convey concern, may appear reassured when they are frightened, or may find questions and instructions confusing or intimidating. The absence of such mechanisms risks misunderstanding children’s symptoms and misinterpreting parental reassurance.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of structured local prompts for recognising neurodivergent symptom expression
Wider context from the report “Local processes provide no structured support for neurodivergent children or parents
Local assessment processes do not contain structured prompts or guidance for recognising how neurodivergence may affect symptom expression or parental communication. Without a structured approach there is a risk that important clinical information will not be elicited or understood , and that apparent agreement with a discharge plan may be misinterpreted.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to carry critical GP information into hospital assessment
Wider context from the report “Critical GP information not carried forward into the hospital assessment
The GP identified the possibility of appendicitis or another serious underlying cause and recorded abnormal observations. The absence of an ambulance conveyance or written referral letter meant this information was not transferred to the hospital. As a result, Ethan entered a different clinical pathway, and the assessing clinician was unaware of the GP’s concerns. There is a wider risk that GPs may not be aware of the implications of referral route on triage and assessment in local hospitals, and that critical deterioration indicators can be lost at the point of transfer.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of GP awareness of referral-route implications for local hospital triage and assessment
Wider context from the report “Critical GP information not carried forward into the hospital assessment
The GP identified the possibility of appendicitis or another serious underlying cause and recorded abnormal observations. The absence of an ambulance conveyance or written referral letter meant this information was not transferred to the hospital. As a result, Ethan entered a different clinical pathway, and the assessing clinician was unaware of the GP’s concerns. There is a wider risk that GPs may not be aware of the implications of referral route on triage and assessment in local hospitals , and that critical deterioration indicators can be lost at the point of transfer.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Absence of computerised safeguards for complete and accurate observations before pathway selection or discharge
Wider context from the report “Absence of computerised mandatory-field safeguards
There is no electronic system with mandatory fields or hard-stops to prevent incorrect or incomplete recording of observations or pain scores. A transposition error between oxygen saturation and temperature occurred. The absence of automated safeguards requiring complete and accurate observations before pathway selection or discharge creates a risk that clinically significant information may be overlooked. Although there is an intention to develop such a system, it is not currently in place.
” 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 referral-route risks and Prevention of Future Deaths learning to members through a generic educational webinar.
Verbatim wording from the response “I intend to communicate this issue to members alongside learning from Prevention of Future Death Reports in a Webinar format for dissemination of learning, ensuring principles being highlighted are generic and not attributable to individual cases, nor impacting ongoing proceedings that follow each coronial review.” Source location Response from Royal College of General Practitioners
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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 Issue a joint statement calling for improved primary-care access to specialist advice and expanded same-day emergency care options.
Verbatim wording from the response “Work on the interface between primary and secondary care included a joint statement between RCGP, RCP, SAM and Royal College of Emergency Medicine calling for secondary care to improve primary care access to specialist advice via dedicated telephone lines and urgent expansion of SDEC options for primary care and 111 services. GP awareness of impact of referral letter and ambulance conveyance on clinical pathways within Emergency care, opportunities to communicate this to GPs.” Source location Response from Royal College of General Practitioners
Open published response
11 Mar 2026 Mark Simpson · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 2 Failure to add NHS 111 consultation reports to patients’ medical records View source Failure to ensure medically informed review and escalation of potentially significant NHS 111 information View source
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AI-generated summary
Mark Simpson · 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
Mark Simpson died on 22 October 2025 after being found unresponsive and not breathing at home; the medical cause of death was acute heart failure due to ischaemic heart disease and coronary artery atheroma, with renal cell carcinoma also recorded. The report raises concerns that information about his NHS 111 consultation for prolonged chest pain was assessed by non-medically qualified staff, was not relayed to a clinician, and was not added to his medical record.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to add NHS 111 consultation reports to patients’ medical records
Wider context from the report “Concern 2
If reports of this nature, forwarded to a GP Practice after a consultation with the NHS 111 Service, are not added to a patient’s medical record at the Practice , should a subsequent consultation become necessary, the medical professional conducting that consultation in the absence of potentially very relevant information may go on to make inappropriate decisions and place their patient at risk .
I believe it is necessary for to raise this concern, but it is not for me to be prescriptive about what should / can be done.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medically informed review and escalation of potentially significant NHS 111 information
Wider context from the report “If a patient contacts the NHS 11 service it is necessary and appropriate for that patient’s GP Practice to be informed. Mark Simpson contacted the NHS 111 service reporting chest pain for approximately seven hours before being advised to call 999 should the pain become dramatically worse or he feel breathless. His GP Practice was provided with a record of that consultation, but this information was not relayed to a clinician nor was it added to Mark's medical record at the surgery.
Concern 1
The information forwarded to the GP Practice was considered by a member of staff who was not medically qualified , and yet in deciding the consultation did not need to be brought to the attention of a medical professional was making an important decision with potentially significant ramifications for that patient.
Notwithstanding that a GP Practice may receive numerous reports about patients of this type, if such potentially significant information is not considered by a member of staff with medical knowledge, important information may be missed and to the later detriment of the patient.
” 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 Ask the Health Informatics Group to examine inconsistent recording of NHS 111 reports and determine whether further escalation or membership communication is required.
Verbatim wording from the response “Action being taken
In taking action, I shall bring these concerns around systems of workflow, coding of information, and the timely availability of correspondence within the clinical record as an agenda item to the Health Informatics Group within the next three months. The RCGP will ask the Group to examine why 111 consultation reports are not consistently recorded in the patient record, and to determine whether action is required to take this forward to the Joint GP IT Committee, to communicate with the wider membership, or both.” Source location 2026-0139 - Response from Royal College of General Practitioners
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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 Use this case to inform guidance, member communications and engagement with system partners on safe handling of clinical correspondence.
Verbatim wording from the response “We are committed to learning from Mr Simpson's death. The RCGP will ensure this case informs our guidance, our communications to members, and our engagement with system partners on the safe handling of clinical correspondence. We would welcome the opportunity to update the Coroner on the outcomes of these actions in due course.” Source location 2026-0139 - Response from Royal College of General Practitioners
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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 Place workflow, information coding and clinical correspondence availability concerns on the Health Informatics Group agenda within three months.
Verbatim wording from the response “Action being taken
In taking action, I shall bring these concerns around systems of workflow, coding of information, and the timely availability of correspondence within the clinical record as an agenda item to the Health Informatics Group within the next three months. The RCGP will ask the Group to examine why 111 consultation reports are not consistently recorded in the patient record, and to determine whether action is required to take this forward to the Joint GP IT Committee, to communicate with the wider membership, or both.” Source location 2026-0139 - Response from Royal College of General Practitioners
Open published response
4 Mar 2026 Roman Louie BARR · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 6 Risk to critically unwell patients and families when families transport patients to hospital during time-critical emergencies View source Delays in ambulance handover reducing emergency ambulance availability View source Failure to reliably identify excessive or repeated requests for salbutamol inhalers View source Lack of a consistent follow-up process for salbutamol overuse patterns View source Limited awareness of the significance of salbutamol overuse in patients and families View source Failure of NHS Pathways triage wording to be readily understood by callers in distress View source See 3 more concerns
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
Roman Louie BARR · 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
Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after no ambulance was available for several hours, leading his family to transport him to hospital. The principal concerns were limited awareness and follow-up of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks to families transporting critically unwell patients, and unclear NHS Pathways triage wording.
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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 Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Risk to critically unwell patients and families when families transport patients to hospital during time-critical emergencies
Wider context from the report “4. Risks when families transport critically unwell patients
The absence of an available ambulance for several hours resulted in the family transporting Roman to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover reducing emergency ambulance availability
Wider context from the report “3. Ambulance handover delays affecting emergency availability
Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought , reducing emergency response capacity during periods of high demand.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably identify excessive or repeated requests for salbutamol inhalers
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems , and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent follow-up process for salbutamol overuse patterns
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur , meaning deteriorating asthma may go unrecognised.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Limited awareness of the significance of salbutamol overuse in patients and families
Wider context from the report “1. Limited awareness of salbutamol overuse
Evidence showed that patients and families may not appreciate the clinical significance of increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS Pathways triage wording to be readily understood by callers in distress
Wider context from the report “5. Clarity of NHS Pathways triage wording
Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information . This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress .
” 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 Clinical teams, rather than GP IT systems, are responsible for establishing recall mechanisms to identify and review patients overusing salbutamol.
Verbatim wording from the response “Systems themselves do not automatically alert examples such as monthly requests for Salbutamol nor incidence of using 3 or more reliever inhalers per year, and it is the responsibility of clinical teams to put in place recall systems and mechanisms to recognise and review those at risk and provide best possible asthma care.” Source location Response from Royal College for GP's
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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 Pathways and ambulance-service concerns fall outside the Royal College of General Practitioners’ remit.
Verbatim wording from the response “Suggestions for concerns regarding the NHS Pathways and Ambulance services are beyond the remit of the Royal College of General Practitioners.” Source location Response from Royal College for GP's
Open published response
4 Mar 2026 Roman Louie BARR · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 6 Limited awareness of salbutamol overuse and its association with poorly controlled asthma View source Delays in ambulance handover at local hospitals View source Failure to reliably identify excessive or repeated requests for salbutamol inhalers View source Failure of NHS Pathways triage wording to be readily understood by callers in distress View source Risk to critically unwell patients and families when no ambulance is available and families transport patients themselves View source Lack of a consistent follow-up process for salbutamol overuse patterns View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Roman Louie BARR · 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
Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after information indicating the need for an urgent ambulance response was not obtained, no ambulance was available for several hours, and his family transported him to hospital. The principal concerns included limited awareness and monitoring of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks when families transport critically unwell patients, and unclear NHS Pathways triage wording.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Limited awareness of salbutamol overuse and its association with poorly controlled asthma
Wider context from the report “1. Limited awareness of salbutamol overuse
Evidence showed that patients and families may not appreciate the clinical significance of increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance handover at local hospitals
Wider context from the report “3. Ambulance handover delays affecting emergency availability
Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably identify excessive or repeated requests for salbutamol inhalers
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems , and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS Pathways triage wording to be readily understood by callers in distress
Wider context from the report “5. Clarity of NHS Pathways triage wording
Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information . This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Risk to critically unwell patients and families when no ambulance is available and families transport patients themselves
Wider context from the report “4. Risks when families transport critically unwell patients
The absence of an available ambulance for several hours resulted in the family transporting Roman to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent follow-up process for salbutamol overuse patterns
Wider context from the report “2. Identification and follow-up of reliever overuse
Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur , meaning deteriorating asthma may go unrecognised.
” Open source report
2 Feb 2026 Avery Jake Hall · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 6 Lack of advice about medication risks when considering having a child View source Candesartan remaining available on repeat prescription during pregnancy View source Failure to provide specific advice to stop Candesartan and identify its pregnancy risk View source Failure to provide additional medication safety advice during antenatal care View source Failure to conduct a detailed review of repeat prescription requests View source Lack of system warnings identifying pregnancy during repeat prescribing View source See 3 more concerns
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
Avery Jake Hall · 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
Avery Jake Hall died at Sunderland Royal Hospital on 13 November 2024, aged four days, after developing global hypoxia and diffuse alveolar damage following his birth. The report was concerned that his mother continued taking Candesartan during pregnancy because she was not given clear and definitive advice to stop it, and that the medication remained available on repeat prescription without warnings identifying her pregnancy.
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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 Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of advice about medication risks when considering having a child
Wider context from the report “Avery’s mother suffered from migraines which were increasing in severity, so she sought advice from her GP when aged 21 years old. She was prescribed Candesartan 4mg by her GP shortly before her 22nd birthday. This was to be taken daily and was placed on a repeat prescription of 28 tablets. The dose was increased to 8mg after 3 months and following a referral, the treatment was endorsed by a Consultant Neurologist at a consultation 4 months after the initial prescription. The evidence revealed that no advice was provided as to the risks of this medication should she be considering having a child .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Candesartan remaining available on repeat prescription during pregnancy
Wider context from the report “Avery’s mother continued to suffer from migraines during her pregnancy and was unaware of the risk posed by taking Candesartan in pregnancy due to a lack of clear and definitive advice about the risk. I am concerned that she was able to resume taking Candesartan approximately 14 days after her initial GP consultation as the medication remained on a repeat prescription which she was able to continue to request during her pregnancy , and each request was approved without a detailed review. The last repeat prescription being approved only 12 days prior to Avery’s birth.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to provide specific advice to stop Candesartan and identify its pregnancy risk
Wider context from the report “Following a positive pregnancy test in April 2024, Avery’s mother sought advice from her GP about which of her prescribed medications were safe to use during pregnancy.
During the telephone consultation with her GP on 11th April 2024 she was given specific advice to avoid using 3 of 6 prescriptions. I am concerned that the evidence highlighted that Avery’s mother was given only generic advice that it was best to avoid all medication during pregnancy but was not given specific advice to stop using Candesartan , and the risk of continuing to take this medication in pregnancy was not identified during this consultation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to provide additional medication safety advice during antenatal care
Wider context from the report “Although Avery’s mother had a number of attendances with clinicians throughout her antenatal care, the evidence revealed that she was given no additional advice regarding the safety of her medication and, whilst she was advised to seek advice from her GP as the prescriber, she did not feel it was necessary to do so having already had such a consultation in April 2024.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a detailed review of repeat prescription requests
Wider context from the report “Avery’s mother continued to suffer from migraines during her pregnancy and was unaware of the risk posed by taking Candesartan in pregnancy due to a lack of clear and definitive advice about the risk. I am concerned that she was able to resume taking Candesartan approximately 14 days after her initial GP consultation as the medication remained on a repeat prescription which she was able to continue to request during her pregnancy, and each request was approved without a detailed review . The last repeat prescription being approved only 12 days prior to Avery’s birth.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of system warnings identifying pregnancy during repeat prescribing
Wider context from the report “I am concerned that despite advice from the GP that it was best to stop all medication during pregnancy, Candesartan remained as a repeat prescription and, in addition to that, there were no warnings placed on the system which would have alerted the clinician approving the request for the repeat prescription that the patient was pregnant thus necessitating a review .
” 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 Maintain a mandatory prescribing assessment within GP specialty training that assesses prescribing for pregnancy and other special groups.
Verbatim wording from the response “To give context to the family, The Royal College of General Practitioners works to improve patient care by encouraging the highest possible standards in general medical practice by supporting members, setting standards, providing education and training, promoting research and advocating and representing the College and its 56,000 members.” Source location Response from the Royal College of General Practitioners
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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 Provide pregnancy-prescribing information resources and links through the RCGP Women’s Health toolkit.
Verbatim wording from the response “Within the RCGP Womens Health toolkit, the breadth of information resources on prescribing in pregnancy are provided with links, including the Specialist Pharmacy Service, (SPS) https://www.sps.nhs.uk/articles/the-risks-and-principles-of-prescribing-in-pregnancy/” Source location Response from the Royal College of General Practitioners
Open published response
30 Oct 2025 Mr Gunaratnam Kannan · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Lack of joint-agency definition of roles and remits for Mental Capacity Act and Mental Health Act assessments View source Lack of training of service providers on the process for referrals for Mental Health Act assessments View source Lack of training of service providers on Mental Capacity Act assessments 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
Mr Gunaratnam Kannan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Gunaratnam Kannan took an overdose of Metformin and Indapamide tablets on 18 March 2025 and initially refused hospital treatment after being assessed as having mental capacity. He was later found confused, with limited consciousness and lacking mental capacity, was taken to hospital, suffered a cardiac arrest and was pronounced deceased on 19 March 2025. The concerns identified were a lack of joint-agency policy and training on Mental Capacity Act and Mental Health Act assessments, including uncertainty about which service should request or undertake a Mental Health Act assessment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of joint-agency definition of roles and remits for Mental Capacity Act and Mental Health Act assessments
Wider context from the report “• Lack of joint agency working/policy work on the Mental Capacity Act Assessments and Mental Health Act Assessments setting out the roles and remit of service providers.
• Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments.
I heard evidence at the inquest from EMAS that it would be for the NHCT crisis team to attend for a MHA assessment if the patient was deemed to have capacity and that EMAS do not make referrals for mental health act assessments. I heard evidence from NHCT that it would be for either the family, GP or the attending medical practitioner , in this case EMAS, to request a MHA assessment. There is a clear lack of understanding between these service providers as to what actions should be taken and by who.
In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of training of service providers on the process for referrals for Mental Health Act assessments
Wider context from the report “• Lack of joint agency working/policy work on the Mental Capacity Act Assessments and Mental Health Act Assessments setting out the roles and remit of service providers.
• Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments.
I heard evidence at the inquest from EMAS that it would be for the NHCT crisis team to attend for a MHA assessment if the patient was deemed to have capacity and that EMAS do not make referrals for mental health act assessments. I heard evidence from NHCT that it would be for either the family, GP or the attending medical practitioner , in this case EMAS, to request a MHA assessment. There is a clear lack of understanding between these service providers as to what actions should be taken and by who.
In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of training of service providers on Mental Capacity Act assessments
Wider context from the report “• Lack of joint agency working/policy work on the Mental Capacity Act Assessments and Mental Health Act Assessments setting out the roles and remit of service providers.
• Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments.
I heard evidence at the inquest from EMAS that it would be for the NHCT crisis team to attend for a MHA assessment if the patient was deemed to have capacity and that EMAS do not make referrals for mental health act assessments. I heard evidence from NHCT that it would be for either the family, GP or the attending medical practitioner , in this case EMAS, to request a MHA assessment. There is a clear lack of understanding between these service providers as to what actions should be taken and by who.
In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.
” 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 Nottinghamshire Healthcare NHS Foundation Trust should reassert processes for acceptable practitioners to initiate urgent referrals.
Verbatim wording from the response “Re-examining specific issues of Mr Kannan’s case is beyond the remit of the College, but it highlights the need for Nottinghamshire HCT to reassert their processes of acceptable medical practitioners instigating urgent referrals to enable best outcomes and prevent future deaths in similar circumstances.” Source location Response from Royal College of General Practitioners
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 Regulation of general practice service provision is outside the College’s role.
Verbatim wording from the response “Although the RCGP does not have a role in the regulation of General Practice service provision, the regulator CQC has made specific reference to areas of mandatory training considerations in General Practice (GP myth buster 70). This specifically mentions that they expect to see evidence of training for Mental Capacity Act and Deprivation of Liberty Safeguards from GP Service providers, which have relevance to the challenging scenario facing professionals and Mr Kannan’s family. Training is provided via external sources, for example e-Learning for Health, CPD UK and other platforms.” Source location Response from Royal College of General Practitioners
Open published response
15 Sep 2025 Linda Janet Sharp · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1 Failure to recognise that a low Wells score does not exclude DVT or PE 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
Linda Janet Sharp · 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
Linda Janet Sharp had repeated presentations to healthcare professionals with symptoms consistent with thromboembolic disease before suffering a cardiac arrest at home and dying on 21 November 2023. The principal concern was that a low Wells score was treated as excluding deep vein thrombosis or pulmonary embolism, without further testing or empirical anticoagulation; expert evidence stated that a Wells score on its own does not exclude either condition.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise that a low Wells score does not exclude DVT or PE
Wider context from the report “Expert evidence was heard which stated that it is fundamentally flawed to conflate a low Wells score with there being no possibility of a deep vein thrombosis (DVT) and/or a pulmonary embolism (PE) . A Wells score on its own does not exclude a DVT or PE .
” 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 Promote the e-learning module through the members’ network and the Chair’s blog.
Verbatim wording from the response “The College has therefore commissioned some internal work through our eLearning team to highlight the specific issue of interpretation of the Wells score. We shall aim to publish this to be available to members in the first quarter of 2026 and the college will be responsible for the production and content of the eLearning module. We shall promote this through our members network and our regular Chair’s blog which reaches out to all 54,000 of our members.” Source location Response from Royal College of General Practitioners
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 Develop an e-learning module highlighting correct interpretation of the DVT Wells score.
Verbatim wording from the response “The College has therefore commissioned some internal work through our eLearning team to highlight the specific issue of interpretation of the Wells score. We shall aim to publish this to be available to members in the first quarter of 2026 and the college will be responsible for the production and content of the eLearning module. We shall promote this through our members network and our regular Chair’s blog which reaches out to all 54,000 of our members.” Source location Response from Royal College of General Practitioners
Open published response
19 May 2025 John Charles Spencer · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1 Failure of GP out-of-hours surgeries to access key GP medical history information after patient consent View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Charles Spencer · 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
John Charles Spencer became unwell on 17 May 2024 and died on 21 May 2024 after a bowel perforation caused by obstruction within a recurrent right inguinal hernia, resulting in purulent peritonitis. The principal concern was that the GP out-of-hours surgery could not access his relevant GP medical history because different computer systems prevented the exchange of information, potentially affecting the examinations undertaken when patients do not report relevant history.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure of GP out-of-hours surgeries to access key GP medical history information after patient consent
Wider context from the report “(1) The GP medical history summary, populated by the GP that a patient is registered to, is not always accessible to a GP out of hours surgery. Evidence was given that there are various reasons for this, including the patient not providing consent for the exchange of this information. However, on some occasions, even when a patient has consented, the patient record systems utilised by the GP registered practice and the GP out of hours surgery, insofar as being different computer systems or for whatever other technological reason, prevented the exchange of information into the GP out of hours surgery. In this case, evidence was heard that the GP practice was using the EMIS system and that the urgent treatment centre (GP out of hours surgery) was using SystmOne. That fact caused the GP out of hours surgery to not be able to access Mr Spencer’s GP medical summary. This situation generates a concern that, providing the patient has consented, key medical information may not be conveyed to the GP out of hours surgery which should be accessible to allow the appropriate exchange of medical information to inform what examinations should take place in an out of hours setting . This concern is particularly significant in circumstances where the patient does not say and/or present with the points in the medical history relevant to the GPs determination about what further examinations should occur flowing from the medical history of the patient.
” 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 Highlight the concerns to the Professional Record Standards Body regarding interoperability.
Verbatim wording from the response “As a College our action shall be to highlight this tragic case to our health informatics group so they can use it in future discussions with NHS England. It is important that the area of Health informatics is not lost with the reorganisation of NHS and that the government both prioritise and progress action in this work. We shall also highlight your concerns to The Professional Record Standards Body (PRSB) who are dedicated to the development and implementation of health and care information standards and for whom this area on interoperability is relevant.” Source location Response from RCGP
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 Making all GP IT systems identical is not possible because government policy promotes plurality among GP IT providers.
Verbatim wording from the response “The innovation in General Practice IT systems has been led partly by a government strategy to create a Plurality of GP IT Providers by increasing the diversity in the marketplace through NHS frameworks like the GP IT Futures Framework and more recently the Tech Innovation Framework. The new Tech Innovation framework has even brought in a new provider into the marketplace in the last few weeks called Medicus Health. It is therefore not possible for all GP IT systems across both the in and out of hours period to be the same. Recognising that there would be patient benefit to other areas of the health system such as the Hospital Emergency Departments for access to the GP Summary work has been carried out to provide interoperability.” Source location Response from RCGP
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 owns the interoperability strategy and GP Connect, so responsibility for this work lies with NHS England.
Verbatim wording from the response “This work currently falls under NHS England who own the dedicated Interoperability strategy as well as GP Connect which is a new national service which enables healthcare staff to view GP patient records significantly improving data sharing between General Practice and other parts of the NHS. It is recognised that as technology progresses the sharing of records improves but within a robust information governance structure and data sharing agreements.” Source location Response from RCGP
Open published response
17 May 2025 Joseph David POWELL · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Failure to book follow-up appointments for patients presenting with mental health difficulties View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joseph David POWELL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joseph David POWELL, aged 28, was found suspended at his home on 6 September 2024 and did not respond to resuscitation. The principal concern was that requiring patients with mental health difficulties to book their own GP follow-up may result in missed reviews and no further medication.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to book follow-up appointments for patients presenting with mental health difficulties
Wider context from the report “1) That not all GPs book follow up appointments for patients presenting with mental health difficulties such as depression, anxiety and post-traumatic stress disorder . Instead, they request that the patient book their own follow up appointment with their GP . This can be difficult for patients who are suffering from mental health difficulties and can result in patients not receiving a follow up appointment with their GP or any further medication.
” 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 Consider GP booking of follow-up appointments where this forms part of a patient's safety plan.
Verbatim wording from the response “The RCGP actively promotes ongoing professional development for its members, and it has a Mental Health Special Interest Group (SIG). As a College our action shall be to highlight this case to the Mental Health SIG to support further promotion of safety planning in suicide prevention for people with mental health conditions and to consider GP booking of appointments where this is a part of the safety plan.” Source location Response from RCGP
Open published response
24 Apr 2025 Jacqueline Anne Potter · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 5 Failure to restrict in-patient access to self-harm websites through secure unit Wi-Fi View source Failure to provide families with codified risk and safety planning information for first overnight leave View source Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care View source Lack of mandatory menopausal training for relevant clinical practitioners View source Failure to recognise the clinical importance of menopausal symptoms and care 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.
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AI-generated summary
Jacqueline Anne Potter · 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
Jacqueline Anne Potter, known as Anne, died on 5 December 2022 after taking a car and deliberately driving into the path of an HGV tanker on the A303 during overnight leave from a psychiatric unit. The report raises concerns about families not receiving a codified risk and safety planning document for a patient’s first overnight leave, unrestricted access to self-harm websites through secure unit Wi-Fi, and inadequate recognition and provision of menopausal care and 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict in-patient access to self-harm websites through secure unit Wi-Fi
Wider context from the report “(2) It transpired during the Inquest that if an in-patient (detained or voluntary) accesses the secure unit Wi-Fi there are no algorithms or ‘search detection features’ to prevent access to websites pertaining to self harm and so these can be readily accessed by a group who are already vulnerable due to their acute mental health presentation with some element of inherent risk of suicide . It was noted, quite rightly, by legal representatives that workplace organisations can block access to certain sites they deem it undesirable for their workforce to access (such as sites relating to gambling, sexually inappropriate content etc) which shows that it is possible to limit access to certain websites and content when using a Wi-Fi provider. By allowing an already vulnerable group to have unfettered access to websites dedicated to self harm creates a risk of further deaths .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to provide families with codified risk and safety planning information for first overnight leave
Wider context from the report “(1) Anne was not sent home for her first overnight leave with any codified ‘Risk’ and ‘Safety Planning’ document. Whilst it was widely accepted in this case that Anne’s husband was well versed and knowledgeable about his wife’s risks and the measures that might be necessary to help keep her safe whilst she was at home, not all families are as involved in their loved one’s psychiatric care, despite the Trust following the Triangle of Care principles.
Whilst families are not mental health practitioners and are not expected to adopt that role within the community there appears to be an opportunity to supply families with a short, codified document dealing with salient points of risks and safety planning when a patient goes for their first overnight leave since being detained . This may equip families with the knowledge to spot signs of declining mental presentation and/or risk and provide them with the knowledge and/or tools to take appropriate steps to assist in safeguarding their loved ones whilst they are in the community.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care
Wider context from the report “(ii) I was told that the Trust has just one ‘menopause specialist’ (a GP) who covers the entire Trust operations . Not all GP surgeries have a menopause specialist practitioner (or access to one) despite a GP usually being the first port of call for women in the community when seeking primary care. Those GP Surgeries who do have a practitioner who acts as a ‘specialist’ is often a GP with a personal interest who has taken the initiative to go on courses and broaden their learning and understanding, rather than any mandatory requirement for a Surgery [or group with multiple surgeries] to have an available community ‘front-line’ specialist .
I was told that the Trust does not have an “expert” in this field and it would be difficult to have one as menopause isn’t a disease or an illness. Whilst I do not dispute that is it not a disease, menopause is a condition; it does have symptoms and it does have recognised presentations, yet there appears to be a failure to recognise this condition as having equal importance to other ailments or diagnoses.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory menopausal training for relevant clinical practitioners
Wider context from the report “(i) Certain elements of medicine and clinical practice training are compulsory but having heard evidence at the Inquest around mandatory and statutory training modules I learnt that this covers areas such as GDPR training and disposal of sharp objects such as syringes. I was surprised to learn that menopausal training is not mandatory in any area of clinical practice or specialism . I am concerned that there is no requirement to undertake essential compulsory menopausal training for those working in ‘relevant’ clinical practices such as Mental Health Practice, Obstetrics and Gynaecology and Oncology, or even general as a general GP.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the clinical importance of menopausal symptoms and care
Wider context from the report “I was told during a previous PFD Response relating to menopausal knowledge and care within the NHS that “It is important to ensure that women understand common symptoms such as anxiety, stress and depression which they might experience during the menopause and where and when to seek help. The NHS website has resources….” This emphasises my concerns entirely; the lack of importance given to menopausal symptoms . If someone has concerns about heart disease, a worrying lump, a broken bone etc they expect to be able to consult a medically qualified professional who has a knowledge and understanding of their condition or presentation and can diagnose and treat accordingly; not just [and I paraphrase] ‘have a look at a website to help’.
I appreciate that each and every woman will experience perimenopause and menopause differently, their individual experience is unique to them and this, to some degree, creates difficulties as a ‘one size fits all’ approach (which is perhaps achievable in other medical specialisms and disciplines) cannot be offered, but the lack of recognition of the importance of this condition remains a significant concern . I had previously been told (back in a 2024 PFD response) of a roll-out of specialist menopausal care and upskilling of GPs but there was little evidence during the inquest that this has happened/is happening and women continue to approach and navigate the menopause without the support of expert clinicians or practitioners who understand and can treat the symptoms they are experiencing .
” Open source report
20 Mar 2025 Lee Derek Jamie ADAMS · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 High toxicity of propranolol at small doses View source Rapid and dose-related absorption of propranolol View source Lack of a specific antidote for propranolol overdose View source Lack of GP awareness of the consequences of excess propranolol ingestion at relatively small doses View source Failure of GPs to ask individuals about gambling habits View source See 2 more concerns
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
Lee Derek Jamie ADAMS · 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
Lee Derek Jamie Adams died after taking an excessive number of propranolol tablets on 24 July 2020, following extensive online gambling and in the context of depressive illness. The substantive concerns included the rapid absorption and high toxicity of propranolol, the lack of a specific antidote, and the need for GPs to consider patients’ gambling habits and the risks of excess propranolol ingestion.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation High toxicity of propranolol at small doses
Wider context from the report “(2) As a drug it is very effective in what it is prescribed for being used for, for example, in the community to treat hypertension, anxiety and migraines. BUT unfortunately, it is highly toxic at even small doses .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Rapid and dose-related absorption of propranolol
Wider context from the report “(1) Propranolol is absorbed quickly (the court heard within 30-60 minutes of ingestion ) and dose related .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of a specific antidote for propranolol overdose
Wider context from the report “(3) There is no specific anti-dote to a propranolol overdose , the only form of treatment is supportive and therefore hospital based .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of GP awareness of the consequences of excess propranolol ingestion at relatively small doses
Wider context from the report “(4) GPs should be aware of the consequences, at relatively small doses, of excess propranolol ingestion ; especially when there is no specific anti-dote and treatment is restricted to supportive measures only.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure of GPs to ask individuals about gambling habits
Wider context from the report “(5) GPs should be reminded to ask individuals about their gambling habits in the same way that they ask about smoking and alcohol.
” 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 Produce and provide a five-minute learning resource alerting GPs to propranolol toxicity risks and prescribing considerations.
Verbatim wording from the response “This risk assessment includes the comprehensive approach of reviewing the level of risk of existing medications for both mental and physical health and their toxicity in overdose. The RCGP has been aware of the risks of Propranolol toxicity and responded to the HSSIB safety investigation to produce a ‘5 minutes to change your practice’ learning resource for GP members on the risks associated with prescribing Propranolol.” Source location Response from Royal College of General Practitioners
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 Gambling Harms Hub accreditation pathway with e-learning, webinars, practice leads and staff-training materials for addressing gambling harms.
Verbatim wording from the response “In addition to the GP curriculum, the RCGP Gambling Harms Hub is available for our members which encourages our members to complete the eLearning course and webinar to be eligible to become a Gambling Harms accredited practice, with an established practice lead who is sent a staff training research pack that is intended for sharing with the practice team. Gambling Harms Accreditation:” Source location Response from Royal College of General Practitioners
Open published response
7 Jan 2025 Thomas Henry Robin Kingston · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 2 Inadequate guidance on persisting with or switching SSRI medication when there is no benefit or adverse side effects View source Inadequate communication of suicide risks associated with SSRI medications 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
Thomas Henry Robin Kingston · 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
Thomas Henry Robin Kingston, a 45-year-old man, died after sustaining a self-inflicted shotgun wound to the head at his parents’ property on 25 February 2024. The report raises concerns about communication of suicide risks associated with SSRI medication and whether guidance to continue or switch SSRI medication is appropriate when there is no benefit or adverse side effects are experienced.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Inadequate guidance on persisting with or switching SSRI medication when there is no benefit or adverse side effects
Wider context from the report “2. Whether the current guidance to persist with SSRI medication or switch to an alternative SSRI medication is appropriate when no benefit has been achieved and/ or especially when any adverse side effects are being experienced .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication of suicide risks associated with SSRI medications
Wider context from the report “1. Whether there is adequate communication of the risks of suicide associated with the selective serotonin reuptake inhibitor (SSRI) medications ,
” 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 Maintain GP Curriculum guidance on effective communication, risk assessment, suicide prevention, prescribing monitoring, and support for patients and carers.
Verbatim wording from the response “General comments
The GP Curriculum includes within its Clinical topic guides a section on Mental Health mentioning a role of the GP to specifically communicate effectively, professionally, and sensitively with patients, relatives and carers, recognising potential difficulties in communicating with people with mental health conditions and the importance of generating and maintaining rapport. There is a recognition to assess risk to make the patients safety a priority and offer patients relatives and carers advice and support regarding prevention, prescribing monitoring, and self-management of both mental and physical multimorbidity. The curriculum recognises the emerging issue of suicide prevention in mental health care.” Source location Response from Royal College of GPs
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 Mental Health toolkit containing evidence-based guidance on medical and psychological treatments for depression and anxiety.
Verbatim wording from the response “It is however usual to switch to a different class if there has not been a benefit or side effects and there are recommendations in the guidance on how to switch drugs safely between classes due to interactions and different bioavailability. It is also important to be clear on the indication for an SSRI and use of diagnostic criteria for both anxiety as well as depression, as the conditions can be separate or combined this can guide various treatment options. The RCGP also has a Mental Health toolkit which provides evidence-based guidelines for medical and psychological treatments for both depression and anxiety.” Source location Response from Royal College of GPs
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 Existing NICE guidance addresses suicide-risk warnings, treatment review and switching antidepressants when SSRIs are ineffective or cause side effects.
Verbatim wording from the response “There are specific guidelines for Depression produced by NICE and most GPs shall follow NICE CKS (Clinical Knowledge Summaries). The guidance specifically covers the consideration of antidepressant drug treatment (using shared decision making to agree an appropriate treatment plan). The guidance includes advising that symptoms of anxiety, agitation, hopelessness, or suicidal ideas may increase when starting treatment, and advise when to seek urgent review. Advice is also given regarding review and switching antidepressant medication. This does mention considering a switch to a drug that the person has previously found helpful or prefers. In this case it is not clear whether there was a previous preference for a particular SSRI.” Source location Response from Royal College of GPs
Open published response
8 Nov 2024 Lacey May Brookman · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to reach a diagnosis in an ill patient View source Failure to recognise retrocaecal appendicitis as a presentation of acute appendicitis or generalised abdominal pain View source Inadequate training of doctors to consider appendicitis as a differential diagnosis for generalised abdominal pain View source Unavailability of bedside or departmental ultrasound scanning for abdominal pain View source Failure to consider appendicitis in patients with abdominal pain View source Failure to use bedside or departmental ultrasound scanning for abdominal pain View source See 3 more concerns
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
Lacey May Brookman · 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
Lacey May Brookman, aged 11, experienced more than a week of abdominal pain and related symptoms before retrocaecal appendicitis was diagnosed after perforation and abscess formation. She underwent surgery and developed severe complications, including coagulopathy, disseminated intravascular coagulation and multiorgan failure, and died on 4 June 2021. Concerns included difficulty recognising retrocaecal appendicitis, and the availability and use of abdominal ultrasound scanning and training for doctors considering the diagnosis.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to reach a diagnosis in an ill patient
Wider context from the report “1. Neither the original GP, the reviewing surgical SHO or surgical registrar considered that Lacey had appendicitis. The Consultant surgeon reviewing Lacey on the 24th, considered she was ill but could not reach a diagnosis.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise retrocaecal appendicitis as a presentation of acute appendicitis or generalised abdominal pain
Wider context from the report “2. Despite the slant of available literature, it was evident retrocaecal appendicitis presentation is not a rare presentation of either acute appendicitis or generalised abdominal pain (both common presenting features in the young)
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of doctors to consider appendicitis as a differential diagnosis for generalised abdominal pain
Wider context from the report “4. The training of doctors in considering the diagnosis as a possible differential to generalised abdominal pain.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Unavailability of bedside or departmental ultrasound scanning for abdominal pain
Wider context from the report “3. The availability and use of bedside/ departmental ultrasound scanning in abdominal pain (e.g. in the young) at any time, but especially out of hours
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to consider appendicitis in patients with abdominal pain
Wider context from the report “1. Neither the original GP, the reviewing surgical SHO or surgical registrar considered that Lacey had appendicitis. The Consultant surgeon reviewing Lacey on the 24th, considered she was ill but could not reach a diagnosis.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to use bedside or departmental ultrasound scanning for abdominal pain
Wider context from the report “3. The availability and use of bedside/ departmental ultrasound scanning in abdominal pain (e.g. in the young) at any time, but especially out of hours
” 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 Embed telephone consultation, triage, and urgent-care knowledge and skills within the GP Curriculum, training, and clinical topic guides.
Verbatim wording from the response “skills to practice safe and comprehensive history taking within a telephone triage context to ensure the most appropriate outcome. The important lesson here is the consideration of the differential diagnosis of appendicitis, the history taking and examination. This point was highlighted as far back as 1961 in the BJGP journal note on Appendicitis ‘A GP who has to rely on his careful assessment of the patient’s symptoms and history should be able to make a much more accurate diagnosis in the majority of cases, than one who relies on less exacting examinations’. We recognise that the general skills for telephone consultation and triage in a modern age are important when General Practice is managing a significant proportion of on the day care.” Source location Response from Royal College of General Practitioners
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 Continue supporting educational resources on appendicitis and managing diagnostic uncertainty through the GP Curriculum and continuing professional development.
Verbatim wording from the response “NHS England and the GIRFT team have recently produced the Best Practice Guide and have an established process for its implementation which supports a whole pathway approach, however the guide does not specifically reference retrocaecal appendicitis. Most GPs refer to NICE CKS guidance which does specifically mention the presentation of retrocaecal appendicitis. The Royal College of General Practitioners remains committed to supporting ongoing educational resources for both the GP Curriculum and Continuing Professional Development in this area.” Source location Response from Royal College of General Practitioners
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 Run regular courses developing safe, comprehensive history-taking and triage skills for telephone consultations.
Verbatim wording from the response “• Remote Consultation and Triage We recognise that original GP undertook a telephone triage consultation but used safety netting which supported the re-presentation with the second GP 3 days later. The college supports General Practitioners and other GP health professionals in undertaking Telephone consultation and Triage skills and runs courses on a regular basis which are often sold out and are a whole day event designed to offer” Source location Response from Royal College of General Practitioners
Open published response
16 Oct 2024 Paul Michael Clark · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to monitor patients with former opioid addiction prescribed opioid painkillers View source Failure to consider the risks of prescribing opioids to patients with former opioid addiction View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Michael Clark · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Michael Clark was found unresponsive at home on 12 May 2024 and died from drug toxicity; the inquest concluded that the death was accidental. The principal concern was that opioid painkillers were prescribed despite his documented previous heroin addiction, without evidence that the risks of reintroducing opioids were considered or monitored, and he subsequently became addicted and took increasing amounts, including non-prescribed opioids.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor patients with former opioid addiction prescribed opioid painkillers
Wider context from the report “The inquest heard evidence that Paul Clark had previously been addicted to heroin. He had been successful in treating his opioid addiction and had remained opioid free for many years. His previous problems with opioids and the risks of opioids for him were well documented within his medical notes. However despite the risks opioid painkillers presented to him he had been started in primary care on opioid based painkillers for reported pain. He had become addicted to them and took them at increasing levels topping them up with non-prescribed opioids. There was no evidence before the inquest that the inherent risks of reintroducing opioids to someone who had previously been addicted to them were considered or monitored . It was accepted in evidence that whilst opioid painkillers can be helpful for treating some patients the risks of treating a patient with a former opioid addiction with opioids were significant and that there needed to be a very well thought out rationale with careful monitoring to avoid increasing the chances of a patient relapsing into addiction through GP prescribed medication and that it was essential that GPs considered this when prescribing.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the risks of prescribing opioids to patients with former opioid addiction
Wider context from the report “The inquest heard evidence that Paul Clark had previously been addicted to heroin. He had been successful in treating his opioid addiction and had remained opioid free for many years. His previous problems with opioids and the risks of opioids for him were well documented within his medical notes. However despite the risks opioid painkillers presented to him he had been started in primary care on opioid based painkillers for reported pain. He had become addicted to them and took them at increasing levels topping them up with non-prescribed opioids. There was no evidence before the inquest that the inherent risks of reintroducing opioids to someone who had previously been addicted to them were considered or monitored. It was accepted in evidence that whilst opioid painkillers can be helpful for treating some patients the risks of treating a patient with a former opioid addiction with opioids were significant and that there needed to be a very well thought out rationale with careful monitoring to avoid increasing the chances of a patient relapsing into addiction through GP prescribed medication and that it was essential that GPs considered this when prescribing .
” 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 Publish and maintain continuing professional development updates on opioid use disorder, medicine dependence, withdrawal symptoms and opioid reduction.
Verbatim wording from the response “Continuing Professional Development” Source location Response from RCGP
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 Develop, launch and widely circulate a repeat-prescribing toolkit supporting safer, collaborative prescribing processes and addressing opioid-prescribing safety concerns.
Verbatim wording from the response “Clinical Policy” Source location Response from RCGP
Open published response
13 Aug 2024 Margaret HUNTLEY · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 7 Insufficient awareness of Steroid Emergency Cards View source Insufficient usage of Steroid Emergency Cards View source Lack of Ambulance Service staff understanding of steroid medication importance and required actions View source Failure of GPs to routinely request Ambulance Service health-condition alerts View source Lack of triage guidance for responding when patients report prescribed steroid medication View source Inadequate GP awareness of the ability to request Ambulance Service health-condition alerts View source Lack of triage guidance for establishing detailed steroid prescription information 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
Margaret HUNTLEY · 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
Margaret Huntley died on 10 December 2022 after deteriorating with multi-organ failure associated with dehydration, lack of exogenous steroids and Covid-19 infection. The report identifies delays in recognising her need for steroid medication and in prescribing and administering it. Concerns included ambulance staff understanding and triage guidance regarding steroid medication, use of Steroid Emergency Cards, and GP awareness of ambulance-service patient alerts.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Insufficient awareness of Steroid Emergency Cards
Wider context from the report “3. It is unclear as to whether Margaret Huntley had been issued with a Steroid Emergency Card and/or information around use of such a Card. I am concerned that there needs to be improved usage, and awareness, of Steroid Emergency Cards .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Insufficient usage of Steroid Emergency Cards
Wider context from the report “3. It is unclear as to whether Margaret Huntley had been issued with a Steroid Emergency Card and/or information around use of such a Card. I am concerned that there needs to be improved usage , and awareness, of Steroid Emergency Cards .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of Ambulance Service staff understanding of steroid medication importance and required actions
Wider context from the report “1. There is a lack of understanding amongst (non-clinical and clinical) Ambulance Service staff as to the importance of steroid medication and the steps to be taken should a patient (a) report that they are prescribed steroid medication and/or (b) present with symptoms potentially consistent with steroid insufficiency/Addison’s Crisis.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure of GPs to routinely request Ambulance Service health-condition alerts
Wider context from the report “4. It was confirmed in evidence that it is possible for GPs to request that an alert is placed on to the Ambulance Service’s system(s) to alert Ambulance Service staff to specific patient health conditions, such as steroid insufficiency. I am concerned that (a) there is inadequate awareness of this ability amongst GP’s; (b) this action is not routinely being taken by GPs .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of triage guidance for responding when patients report prescribed steroid medication
Wider context from the report “2. There is not, within the NHS Pathways system or otherwise, guidance or processes for Ambulance Service staff triaging calls, including non-clinically qualified staff, to follow regarding (a) the importance of steroid medication and the need to establish, if a patient raises during a call that they are prescribed steroid medication, detailed information regarding that prescription to include the type of prescription and the reasons for it; (b) actions to be taken or processes to follow should a patient raise during a call that they are prescribed steroid medication .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Inadequate GP awareness of the ability to request Ambulance Service health-condition alerts
Wider context from the report “4. It was confirmed in evidence that it is possible for GPs to request that an alert is placed on to the Ambulance Service’s system(s) to alert Ambulance Service staff to specific patient health conditions, such as steroid insufficiency. I am concerned that (a) there is inadequate awareness of this ability amongst GP’s ; (b) this action is not routinely being taken by GPs.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of triage guidance for establishing detailed steroid prescription information
Wider context from the report “2. There is not, within the NHS Pathways system or otherwise, guidance or processes for Ambulance Service staff triaging calls, including non-clinically qualified staff, to follow regarding (a) the importance of steroid medication and the need to establish, if a patient raises during a call that they are prescribed steroid medication, detailed information regarding that prescription to include the type of prescription and the reasons for it ; (b) actions to be taken or processes to follow should a patient raise during a call that they are prescribed steroid medication.
” Open source report
2 Apr 2024 Andrew Ewin-Ripp · Prevention of Future Deaths report East London
View report summary
Concerns raised 7 Failure to require practitioners to pass essential epilepsy information to patients on discharge View source Lack of guidance on contacting the secondary care team after recurrent seizures View source Lack of discharge guidance on maintaining medication compliance despite prolonged seizure freedom View source Lack of required annual epilepsy reviews in general practice View source Lack of a care pathway for urgent neurology reviews in response to patient concerns View source Lack of discharge guidance on notifying clinicians about recurrent seizures View source Lack of clear guidance on longer-term epilepsy monitoring and safe discharge timing View source See 4 more concerns
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
Andrew Ewin-Ripp · 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
Andrew Ewin-Ripp, who had epilepsy, suffered a fit at home on 1 November 2022, was found in cardiac arrest, and died in hospital on 4 November 2022. The reported cause of death was sudden unexpected death in epilepsy (SUDEP). Concerns included lengthy waits for neurology care, the absence of clear guidance and systems for monitoring, discharge information, and urgent review after seizure recurrence.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to require practitioners to pass essential epilepsy information to patients on discharge
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge .
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on contacting the secondary care team after recurrent seizures
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures . There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of discharge guidance on maintaining medication compliance despite prolonged seizure freedom
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period ; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of required annual epilepsy reviews in general practice
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients , as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of a care pathway for urgent neurology reviews in response to patient concerns
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns , such as a return of seizures or not tolerating medication.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of discharge guidance on notifying clinicians about recurrent seizures
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on longer-term epilepsy monitoring and safe discharge timing
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy . How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this .
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” 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 Provide members with SUDEP and seizure-safety education, including epilepsy-review and safety-checklist resources.
Verbatim wording from the response “▪ SUDEP
We currently have a resource available to members specifically on SUDEP and Seizure Safety (first produced in 2016 and updated in 2021). https://sudep.org/article/sudep-action-rcgp-launch-sudep-e-learning. It emphasises the role of General Practice in carrying out Epilepsy reviews using video and case studies in a 30min online resource. It highlights the use of the SUDEP and Seizure safety checklist https://sudep.org/checklist with resources for both professionals and patients. This course is free to access to all 54,000 RCGP members.” Source location Response from Royal College of General Practitioners
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 Provide an epilepsy diagnosis and management learning module and podcast promoting regular annual review.
Verbatim wording from the response “▪ Epilepsy Diagnosis and Management
We also have a series of regular Essential Knowledge Updates. In our Update 17 (April 2016 updated April 2024) there is a specific module on Epilepsy Diagnosis and management. A podcast freely available to all in which ████████ talks about and promotes the e learning module highlighting the importance of regular annual review (EKU17: Epilepsy https://podcasts.apple.com/gb/podcast/eku17-epilepsy/id1474942018?i=1000453462614 )” Source location Response from Royal College of General Practitioners
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 Commissioning general practice services is the responsibility of NHS England, not the respondent.
Verbatim wording from the response “The College is not responsible for Commissioning Services from General Practice. In England this role falls to NHS England. General Practice has however been funded for Epilepsy management through the GMS contract and Quality and Outcomes Framework (QOF) since 2004. There is a requirement to maintain a register of adults receiving drug treatment for Epilepsy (EP001). Between 2004 and 2014 there were 2 additional indicators which fell out of the annual review process i.e. those who were seizure free (EP002) and the number of women receiving information and counselling about reproductive issues (EP003). The EP002 and EP003 indicators were retired in 2014 by NHS England. There has just been a Government Consultation which closed on the 7ᵗʰ March around the future of incentives in General Practice including QOF so there may be changes in coming years.” Source location Response from Royal College of General Practitioners
Open published response
Concerns raised 5 Lack of provision of mental health care for people waiting for gender-affirming treatment View source Delays in access to gender-affirming healthcare View source Lack of clarity for Primary Care clinicians supporting young transgender individuals View source Lack of clarity for mental health clinicians supporting young transgender individuals View source Lack of knowledge and training for managing and offering mental health care to transgender people View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alice LITMAN · 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
Alice Litman, a 20-year-old trans female, was found dead on 26 May 2022 after a descent from height. The report raised concerns about mental-health training and support for transgender people, delays in accessing gender-affirming healthcare, and insufficient clarity and provision of care while awaiting treatment.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of provision of mental health care for people waiting for gender-affirming treatment
Wider context from the report “c) The lack of provision of mental health care for those waiting for gender affirming 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 Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Delays in access to gender-affirming healthcare
Wider context from the report “b) The delays in access to gender affirming healthcare .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity for Primary Care clinicians supporting young transgender individuals
Wider context from the report “d) The lack of clarity for clinicians who are in place to support young transgender individuals in Primary 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 Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity for mental health clinicians supporting young transgender individuals
Wider context from the report “e) The lack of clarity for clinicians who are in place to support young transgender individuals in the Mental Health Setting .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge and training for managing and offering mental health care to transgender people
Wider context from the report “a) The knowledge and training for those in the mental health setting for managing and offering care to those in the transgender community .
” 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 Author a specific transgender policy document.
Verbatim wording from the response “RCGP has been concerned regarding the support and services for transgender individuals for many years. In this regard we have worked with NHS England and equivalent organisations in Devolved Nations, with the General Medical Council and others over this time to improve the knowledge and understanding of the needs of these patients. This has included specific e learning packages which are available on our website as well as authoring a specific transgender policy document. Specifically, our recommendations are (see - https://www.rcgp.org.uk/representing-you/policy-areas/transgender-care)” Source location Response from Royal College of Genereal Practitioners
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 Participate in the current review led by a former Royal College of Paediatrics and Child Health president.
Verbatim wording from the response “It is worth noting that RCGP has been represented at the current review being undertaken by Professor ████████, Former President of the Royal College of Paediatrics and Child Health and our understanding is that we do not expect any change in the view that such individuals need timely access to specialist care and that general practitioners would not be expected to make decisions on treatment. With regard to adult patients, RCGP is supportive of potential plans by NHS England to have a system of regional hubs whereby guidance and support can be sought and especially in wider aspects of care such as sexual health, mental health support and safeguarding as well as prescribing.” Source location Response from Royal College of Genereal Practitioners
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish specific transgender-care e-learning packages on the RCGP website.
Verbatim wording from the response “RCGP has been concerned regarding the support and services for transgender individuals for many years. In this regard we have worked with NHS England and equivalent organisations in Devolved Nations, with the General Medical Council and others over this time to improve the knowledge and understanding of the needs of these patients. This has included specific e learning packages which are available on our website as well as authoring a specific transgender policy document. Specifically, our recommendations are (see - https://www.rcgp.org.uk/representing-you/policy-areas/transgender-care)” Source location Response from Royal College of Genereal Practitioners
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 Decisions on specific therapy, including medication, are specialist responsibilities outside general practitioners’ scope of practice.
Verbatim wording from the response “A particular focus from members has been the continuing very long waiting lists for access to specialist advice and care. This has been especially a concern regarding children and young people where the waiting lists are frequently over 2 years in duration but also for adult patients, where access can be very difficult. The RCGP’s view is that for Children and Young people, GPs can provide holistic general care and support to the individual and their family, however decisions on whether or when to provide specific therapy such as medication is a specialist area of responsibility and outwith the scope of practice of general practitioners.” Source location Response from Royal College of Genereal Practitioners
Open published response
15 Aug 2023 Leonard Jomo Isaac KING · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Failure to recognise epiglottitis in adults 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
Leonard Jomo Isaac KING · 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
Leonard Jomo Isaac King died at Milton Keynes University Hospital on 4 May 2022 following a hypoxic cardiac arrest caused by airway obstruction from epiglottitis. The report identified concerns that adult epiglottitis may be mistaken for a sore throat or tonsillitis, and that there were missed opportunities to recognise and escalate his condition and transfer him to an emergency department.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise epiglottitis in adults
Wider context from the report “Subsequent to mass immunisation the demographic has changed and more adults are developing epiglottitis. It is not common in this group but because of the expectation among clinicians that it is a still a disease of children, there is a tendency, except in those routinely dealing with acute emergencies of the airways, to regard typical symptoms as those of a sore throat or tonsillitis and not as the harbinger of sudden catastrophic obstructive epiglottitis .
The disease classically develops rapidly in children but in adults may take several days which may be falsely reassuring . Typical symptoms may include a sore throat which becomes more severe with time, difficulty swallowing secretions, pain on swallowing and an alteration in voice. Prompt recognition and treatment is lifesaving.
” Open source report
28 Mar 2023 Louis James Rogers · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Failure to document general practice assessment of febrile seizures View source Failure to make timely referrals from general practice to secondary medical services for febrile seizures View source Sudden unexpected death in childhood following febrile seizures View source Failure to make paramedic information available to all clinicians View source Lack of coordinated response across clinicians to febrile seizure presentations View source Delays in referral for assessment and investigation of febrile seizures View source Failure to ensure febrile seizure diagnoses are supported by the child’s presentation View source Failure to undertake a detailed history and full neurological examination in general practice View source Failure to follow escalation guidance for complex febrile seizures View source Insufficient information for parents and guardians after a child’s febrile seizure View source See 7 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
Louis James Rogers · 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
Louis James Rogers died after being found unresponsive at home following a period of clinical illness and was pronounced dead on 18 June 2021 despite resuscitation attempts. Autopsy identified a viral infection, and genetic studies confirmed Dravet’s Syndrome. The report raised concerns about the management and investigation of febrile seizures, information provided to parents, paramedic and general practice guidance, and the lack of a coordinated febrile seizure pathway.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to document general practice assessment of febrile seizures
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely referrals from general practice to secondary medical services for febrile seizures
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Sudden unexpected death in childhood following febrile seizures
Wider context from the report “1. Management and investigation of Febrile Seizures
Evidence was heard that a number of children who have ‘febrile’ seizures subsequently die from ‘sudden unexpected death in childhood’ . Evidence was provided that there should be greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures. Further evidence was heard that referrals for assessment and investigation of febrile seizures should be undertaken earlier to exclude a more severe underlying illness.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to make paramedic information available to all clinicians
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of coordinated response across clinicians to febrile seizure presentations
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Delays in referral for assessment and investigation of febrile seizures
Wider context from the report “1. Management and investigation of Febrile Seizures
Evidence was heard that a number of children who have ‘febrile’ seizures subsequently die from ‘sudden unexpected death in childhood’. Evidence was provided that there should be greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures. Further evidence was heard that referrals for assessment and investigation of febrile seizures should be undertaken earlier to exclude a more severe underlying illness.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure febrile seizure diagnoses are supported by the child’s presentation
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a detailed history and full neurological examination in general practice
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to follow escalation guidance for complex febrile seizures
Wider context from the report “3. Improvement to and highlighting of the JRCALC guidelines for paramedic management of seizures in children
JRCALC guidelines indicated paramedics should have conveyed Louis to hospital or contacted the GP and/or Out of Hours GP service following Louis’s second seizure on 11th February 2020, as the close proximity of two seizures indicated it was a ‘complex febrile seizure’ rather than a febrile seizure. This led to a lost opportunity to expeditiously trigger further investigation and/or a referral to either the ‘first seizure’ service or to a specialist paediatrician for further assessment and management. Evidence was heard that improving and highlighting JRCALC guidelines with additional teaching would prevent this happening again.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Insufficient information for parents and guardians after a child’s febrile seizure
Wider context from the report “2. Information provided to parents/guardians after their child had a Febrile Seizure
Evidence was heard that the NHS website and pamphlet provided to parents/guardians following a child’s febrile seizure is insufficiently informative to provide parents with sufficiently detailed information to assist them in picking up potential early indicators of a more severe illness e.g. issues with gait, co-ordination, definition of complex seizures, developmental regression etc.
” Open source report
Concerns raised 5 Failure to consider the timing of requests for advice in 111 dispositions View source Failure to accommodate prior direct general practitioner review in 111 dispositions View source Lack of detailed assessment of the degree of apparent concern View source Unavailability of accessible paediatric infrastructure in an out-of-hours GP service View source Failure to question the nature of vomitus in young children View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Esma GUZEL · 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
Esma Guzel, aged five, died on 10 May 2019 after developing vomiting and abdominal pain due to complications of a congenital diaphragmatic hernia. After a GP assessment and subsequent deterioration, the 111 service advised attendance at an out-of-hours GP service, where she arrived in cardiac arrest and could not be resuscitated. The principal concerns relate to questioning about vomitus, the 111 algorithm’s assessment and disposition, and referral to paediatric 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 Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the timing of requests for advice in 111 dispositions
Wider context from the report “I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice , when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to accommodate prior direct general practitioner review in 111 dispositions
Wider context from the report “I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner , and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed assessment of the degree of apparent concern
Wider context from the report “I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern , no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Unavailability of accessible paediatric infrastructure in an out-of-hours GP service
Wider context from the report “I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation. The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure , where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Failure to question the nature of vomitus in young children
Wider context from the report “I have presented with evidence prior to and at inquest, that diligent questioning as to the nature of vomitus in a five-year-old patient, would have alerted a competent practitioner to the requirement for urgent hospitalisation . The facts of this case are that with the child continuing to be unwell eight hours later, the 111 algorithm led to her being driven by her father to an out-of-hours GP run service with no accessible paediatric infrastructure, where she arrived in a state of cardiac arrest. The 111 algorithm has been subject to modification in the light of these events, but I remain concerned that there is no detailed assessment of the degree of apparent concern, no accommodation of the prior direct review by a general practitioner, and no consideration of the timing of the request for advice, when reaching a disposition that does not involve referral to paediatric services. It is difficult to reconcile professional opinion that this patient should have been referred to paediatric services on the basis of features at 5 PM but not in the small hours of the morning with a deterioration in her condition by that stage. I have heard in evidence that an educational message on ‘rare causes for common symptoms’ could be circulated as a case report, but take the view that the lead professional bodies for both general practice and child health should consider how such information is effectively disseminated, and whether the algorithms and dispositions generated by the 111 service need further modification to maximise the chance of expedited optimal care for what is acknowledged to be an uncommon condition. I have heard in evidence that the 111 service is the default safety net arrangement in such circumstances, and this therefore requires endorsement by your professional bodies, if it is to command the confidence of patients, parents and practitioners as a definitive safety net.
” 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 Provide a children’s and young people’s curriculum covering paediatric emergencies, gastrointestinal conditions, examinations and complex-disease liaison, with trainee assessment before qualification.
Verbatim wording from the response “GP in training curriculum
Paediatrics and child health is covered extensively in the RCGP curriculum which contains a Children’s and Young People’s specific curriculum that all GPs in training follow. This includes several areas that would relate to this case including common and important conditions such as paediatric emergencies, congenital abnormalities, gastrointestinal conditions that present in childhood, age-appropriate examinations and liaising with colleagues for complex disease. GPs in training would be assessed on their knowledge of this aspect of the curriculum in workplace-based assessments, the applied knowledge test (a written exam) and in a recorded consultation assessment before a GP trainee could qualify and work independently as a GP.” Source location Response from Royal College General Practitioners
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 Investment to enable primary-care and out-of-hours record sharing would require action by NHS England, NHS Improvement and the Department of Health and Social Care.
Verbatim wording from the response “Sharing of data/ clinical notes between primary care and the out-of-hours service
There are some out-of-hours services who are able to see the whole GP record. It does not appear in this case it was possible from the Regulation 28 report. If both the out-of-hours service and the GP surgery use the same electronic notes system it is possible, with patient consent, to share all of the GP record. However, in many areas, the GP record is not visible to the out-of-hours service as both use different digital platforms. The RCGP would welcome investment in primary care (both GP and out-of-hours services) infrastructure, to enable best practice of sharing of all notes, subject to patient consent, to be rolled out across the NHS to benefit patient care. However, we recognise this will require significant investment form NHS England and NHS Improvement and the Department of Health and Social Care.” Source location Response from Royal College General Practitioners
Open published response
28 Apr 2022 Susan Elizabeth Carling · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Suicides among health service professionals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Elizabeth Carling · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Susan Elizabeth Carling, a General Practitioner, died by suicide at her home address on 2 January 2022. The report raises concern about suicide among health-service professionals and the need to highlight available support for GPs and this vulnerable professional group.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Suicides among health service professionals
Wider context from the report “Her family brought to my attention that there are approximately 100 people in the health service who commit suicide each year . They requested that in my role to prevent future deaths that this is considered by someone who could potentially take action to prevent future deaths in this profession going forward.
I am aware and made it clear to the family that there are organisations that GP’s can access for support however they like I agree that this needs to be highlighted if suicides are to be prevented in this vulnerable professional group .
” 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 Co-launch coaching support services with NHS England and Improvement for primary care workers, managers and leaders.
Verbatim wording from the response “2. NHS England and Improvement, in collaboration with the RCGP has launched the #LookingAfterYouToo and the #LookingAfterYourTeam coaching support services. These services provide access to mental health services to all primary care workers, managers and leaders employed or contracted to deliver work on behalf of the NHS.” Source location Response from Royal College of General Practioners
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 Provide new members with details of existing support services when they join.
Verbatim wording from the response “The RCGP provides a suite of support to all its members and fellows. Specifically” Source location Response from Royal College of General Practioners
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 Signpost members to wellbeing and mental-health support services through the College website.
Verbatim wording from the response “4. Signposting to wellbeing and mental health support via our website, including:” Source location Response from Royal College of General Practioners
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 Lobby on behalf of GPs for workload reduction.
Verbatim wording from the response “Within the medical profession, GPs are currently most at risk from suicide and in essence working in front line general practice must be now seen as a major risk factor for suicide. Any action to reduce the workload should also be seen as supportive, and the College has been lobbying on behalf of all GPs for this to happen. Sadly, this lobbying is tending to fall on deaf ears, and workload, and in particular its intensity continues to rise, as does the high levels of suicidal thoughts, and number of complete suicides.” Source location Response from Royal College of General Practioners
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 Maintain wellbeing resources and member-led webinars covering GP wellbeing, emergency contacts and help lines.
Verbatim wording from the response “3. We have a suite of wellbeing resources and webinars led by college members and available to all our members and fellows. https://www.rcgp.org.uk/membership/gp-wellbeing
These resources are all around GP wellbeing, emergency contacts and help lines.
The help me, I'm a doctor site brings together five independent charities that support doctors when they need confidential financial assistance. They can provide support to help doctors in genuine financial need get their lives and careers back on track.” Source location Response from Royal College of General Practioners
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 medical specialties are responsible for assessing how to reduce workload transferred to primary care.
Verbatim wording from the response “The group identified key issues affecting GPs though these issues are universal as risk factors, the only difference being the level of the risk. The main issues relate to unsustainable and intolerable workload and for GPs coupled with negative press and constant unfair blame directed at them. The group also noted that there has been little recognition of impact and toll of the pandemic on mental health of workforce and that as we emerge from it, staff numbers have gone down whilst patient demand up.” Source location Response from Royal College of General Practioners
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 Politicians and the media are responsible for changing public discourse and acknowledging pressures affecting NHS and primary care staff.
Verbatim wording from the response “It is important that whilst you have asked us, that is the RCGP as to what is being done to support our colleagues, that suicide amongst doctors needs a collective approach towards prevention with policy makers, politicians and professional bodies all involved in reducing this needless loss of life.” Source location Response from Royal College of General Practioners
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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 National and political bodies are responsible for commissioning, contracting, workforce planning and workload-flow changes affecting primary care.
Verbatim wording from the response “It is important that whilst you have asked us, that is the RCGP as to what is being done to support our colleagues, that suicide amongst doctors needs a collective approach towards prevention with policy makers, politicians and professional bodies all involved in reducing this needless loss of life.” Source location Response from Royal College of General Practioners
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 Individual clinicians are responsible for allowing themselves time and space to address their own wellbeing and prevent deterioration.
Verbatim wording from the response “It is important that whilst you have asked us, that is the RCGP as to what is being done to support our colleagues, that suicide amongst doctors needs a collective approach towards prevention with policy makers, politicians and professional bodies all involved in reducing this needless loss of life.” Source location Response from Royal College of General Practioners
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 Organisational and local bodies are responsible for addressing workload-demand mismatches and system pressures affecting clinicians.
Verbatim wording from the response “It is important that whilst you have asked us, that is the RCGP as to what is being done to support our colleagues, that suicide amongst doctors needs a collective approach towards prevention with policy makers, politicians and professional bodies all involved in reducing this needless loss of life.” Source location Response from Royal College of General Practioners
Open published response
21 May 2021 Dyllon Shaun Graham Milburn · Prevention of Future Deaths report Manchester City
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Concerns raised 1 Lack of patient alerts for requesting and collecting repeat prescriptions 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
Dyllon Shaun Graham Milburn · 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
Dyllon Shaun Graham Milburn died on 8 October 2019 in the garden of his home in Manchester from asphyxiation using a ligature made from a scarf. He had been prescribed Sertraline and had periods of non-compliance. The report raised concern that the repeat-prescription system did not allow automated alerts to remind patients to request and collect their medication.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of patient alerts for requesting and collecting repeat prescriptions
Wider context from the report “The system for repeat prescriptions does not currently allow for alerts to be sent to a patient to remind them to request and collect their repeat prescription to encourage compliance.
” Open source report
20 Apr 2021 Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Insufficient undergraduate teaching on the health effects of air pollution View source Insufficient postgraduate education on the health effects of air pollution View source Insufficient detail and monitoring capacity for air quality information View source Insufficient professional guidance on communicating the health effects of air pollution View source Low public awareness of sources of national and local pollution information View source National Particulate Matter limits exceeding WHO guideline levels View source See 3 more concerns
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
Ella Adoo-Kissi-Debrah · 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
Ella Adoo-Kissi-Debrah died aged 9 after an asthmatic episode led to cardiac arrest on 15 February 2013. The report states that air pollution, including exposure to nitrogen dioxide and particulate matter from traffic emissions, significantly contributed to her asthma and death. It also identifies concerns about pollution limits, public access to pollution information, and communication of air-pollution health risks by healthcare professionals.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Insufficient undergraduate teaching on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Insufficient postgraduate education on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail and monitoring capacity for air quality information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors .
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional guidance on communicating the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Low public awareness of sources of national and local pollution information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government . The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.
” 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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation National Particulate Matter limits exceeding WHO guideline levels
Wider context from the report “(1) The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.
” 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 Deliver a high-profile webinar for GPs incorporating air-pollution content within broader planetary-change coverage.
Verbatim wording from the response “We are also aware that Health Education England are considering an on-line planetary education programme. RCGP is already in the process of producing a planetary health element of a curriculum that all new GP will be assessed against. In the near term we are also planning a high profile webinar that GPs would be able to access and whilst it would have a broader approach to planetary change, it would incorporate elements regarding pollution.” Source location 2021-0113-Response-from-Royal-College-of-General-Practitioners-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 Produce a planetary-health curriculum element against which all new GPs will be assessed.
Verbatim wording from the response “We are also aware that Health Education England are considering an on-line planetary education programme. RCGP is already in the process of producing a planetary health element of a curriculum that all new GP will be assessed against. In the near term we are also planning a high profile webinar that GPs would be able to access and whilst it would have a broader approach to planetary change, it would incorporate elements regarding pollution.” Source location 2021-0113-Response-from-Royal-College-of-General-Practitioners-Redacted
Open published response
13 Apr 2021 ANN COLES · Prevention of Future Deaths report Surrey
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Concerns raised 1 Lack of required lung imaging for patients prescribed amiodarone long term 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
ANN COLES · 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
Ann Coles was admitted to Frimley Park Hospital in March 2019 with pneumonia and later developed multi-organ failure, dying on 12 March 2019. The principal concern was that long-term amiodarone can cause lung toxicity and fibrotic changes, while there was no requirement for lung imaging to monitor patients prescribed the medication long term.
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 College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of required lung imaging for patients prescribed amiodarone long term
Wider context from the report “The evidence showed that a potential side effect of amiodarone medication is that it can cause toxicity which affects the lungs and can cause fibrotic changes. In her evidence the consultant cardiologist who treated Ann in her final illness raised the concern that there is no requirement for lung imaging to be undertaken when patients are prescribed amiodarone on a long term basis which in her view was a glaring gap in the oversight necessary for the effects of the medication.
” 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 Medication regulation falls outside the organisation’s functions, although it guides standards and provides education.
Verbatim wording from the response “The Royal College of General Practitioners is not a regulating organisation and especially not for medication although we do have responsibilities in guiding standards and providing education. Regulatory responsibility of medication lies with The Medicines and Healthcare products Regulatory Agency (MHRA). Given the concerns raised in your inquest, I recommend that you request the MHRA comment upon this matter. Contact details are here.” Source location 2021-0101-Response-from-Royal-College-of-General-Practitioners-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 The MHRA holds regulatory responsibility for medication and should address the concerns about amiodarone monitoring.
Verbatim wording from the response “The Royal College of General Practitioners is not a regulating organisation and especially not for medication although we do have responsibilities in guiding standards and providing education. Regulatory responsibility of medication lies with The Medicines and Healthcare products Regulatory Agency (MHRA). Given the concerns raised in your inquest, I recommend that you request the MHRA comment upon this matter. Contact details are here.” Source location 2021-0101-Response-from-Royal-College-of-General-Practitioners-Redacted
Open published response
21 Dec 2020 James Alexander David Taylor · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Lack of care summaries when complex patients transfer between GP surgeries 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
James Alexander David Taylor · 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 Alexander David Taylor died as a result of suicide after sustaining life-changing injuries in a road traffic collision, which led to refractory pain, sensory disturbances, psychological distress and suicidal ideation. The inquest heard that required long-term psychological therapy was not provided and that his participation in a functional neurological disorder programme ended after four days because of pain. Concerns were also raised about repeated changes of GP surgery, lack of continuity of care, and the absence of a clear transfer summary for his complex medical needs.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of General Practitioners; that does not assign responsibility.
PFD Monitor interpretation Lack of care summaries when complex patients transfer between GP surgeries
Wider context from the report “As a result of his complex health needs, Mr Taylor changed address on a number of occasions. This required a number of changes of general practitioner surgeries. In 4 years, Mr Taylor had changed surgeries 4 times. The Inquest heard evidence from his final general practitioner who confirmed that there was a large volume of records relating to Mr Taylor. The GP confirmed that no summary of care is provided to GP practices when transfer of patients take place. He confirmed the dangers of this, in that important clinical matters can be missed where a patient has a large volume of records.
The general practitioner indicated that handover summaries should be provided to GPs when complex patients are transferred from surgery to surgery. Such transfer summaries could include a summary of past medical history and highlight acute, ongoing clinical conditions, together with any safeguards around prescribing of medication. Such summaries could ensure safety in the continuity 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 Primary Care Support England, rather than the College, is responsible for the system of transferring GP records.
Verbatim wording from the response “The responsibility for the system of transferring records lies with Primary Care Support England rather than RCGP, but our position is to support electronic transfer for the reasons articulated above.” Source location 2020-0300-Response-from-Royal-College-of-GPs-Redacted
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations