20 Jun 2025 Finlay Joshua ROBERTS · Prevention of Future Deaths report Inner North London
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Concerns raised 3 Lack of paediatric nursing observations View source Failure of medical staff to recognise absent nursing observations View source Failure to complete final nursing observations before discharge View source
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Finlay Joshua ROBERTS · 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
Finlay’s parents took him to Whittington Hospital the night before he died, during an extremely busy and understaffed night in the paediatric emergency department. The report describes failures to conduct serial nursing observations, complete appropriate tests, and obtain specialist advice before Finlay was discharged home. The principal concerns were that missing nursing observations may be a wider issue and that medical staff failed to recognise that the observations had not been carried out.
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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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Lack of paediatric nursing observations
Wider context from the report “The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff.
However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks.
I remain concerned on two counts:
1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.
2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure of medical staff to recognise absent nursing observations
Wider context from the report “The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff.
However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks.
I remain concerned on two counts:
1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.
2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure to complete final nursing observations before discharge
Wider context from the report “The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff.
However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks.
I remain concerned on two counts:
1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.
2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.
” 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 Collaborate with RCPCH to revise emergency care standards for children and young people, including requirements concerning observations.
Verbatim wording from the response “The RCN is also collaborating with the RCPCH in the revision of the emergency care standards for children and young people which will specify that observations are part of holistic care and repetition is dependent on the child’s well-being, alongside clarification around frequency of observations.” Source location 2025-0316 Response from Royal College of Nursing
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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 educational material supporting implementation of the System-wide Paediatric Observations Tracking Programme.
Verbatim wording from the response “The RCN has been collaborating with NHS England and the Royal College of Paediatric and Child Health (RCPCH) to develop a single national paediatric early warning system (PEWS) for England since 2018 and are supportive of equivalent processes across the UK. The RCN has produced supportive educational material to support the role out of this initiative System wide Paediatric Observations Tracking Programme. This work is aimed for implementation across the four-nations in the UK.” Source location 2025-0316 Response from Royal College of Nursing
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 Collaborate with NHS England and RCPCH to develop a single national paediatric early warning system for England.
Verbatim wording from the response “The RCN has been collaborating with NHS England and the Royal College of Paediatric and Child Health (RCPCH) to develop a single national paediatric early warning system (PEWS) for England since 2018 and are supportive of equivalent processes across the UK. The RCN has produced supportive educational material to support the role out of this initiative System wide Paediatric Observations Tracking Programme. This work is aimed for implementation across the four-nations in the UK.” Source location 2025-0316 Response from Royal College of Nursing
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 nursing practice and the reported concerns fall outside the organisation’s regulatory functions and authority.
Verbatim wording from the response “We are not the regulator for nurses in the UK, nor do we have any control over individual nursing practice in individual workplaces; therefore, we have no remit to address the concerns you have noted in respect of this death. However, the RCN offers a suite of learning resources to support nurses, students, nursing support workers, midwives, and health care professionals at all stages of their careers. We provide expert-led, quality-assured, evidence-based education for continuing professional development CPD and learning on a range of topics and subjects.” Source location 2025-0316 Response from Royal College of Nursing
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8 Aug 2024 Mrs Gillian Patricia Stokes · Prevention of Future Deaths report Surrey
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Concerns raised 5 Lack of clinical guidance for recognising possible radiation-induced sarcoma View source Failure to clearly communicate required follow-up to families View source Lack of protocols for first-line investigation of patients with breast implants after radiotherapy View source Failure to complete scheduled two-week follow-up after aspiration View source Insufficient duration of surveillance for radiation-induced sarcoma after breast cancer 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
Mrs Gillian Patricia Stokes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Gillian Patricia Stokes died from sarcoma of the right chest wall after previously receiving radiotherapy for breast cancer and having breast reconstructive surgery with an implant. The report raises concerns about insufficient guidance for identifying radiation-induced sarcoma and imaging the chest wall in patients with implants, the five-year surveillance period after breast cancer, and the failure to arrange a recommended two-week follow-up after aspiration.
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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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical guidance for recognising possible radiation-induced sarcoma
Wider context from the report “(1) I am concerned that there is not any or insufficient guidance available to clinicians in regard to possible radiation induced sarcoma , or first line investigations for patients with breast implants to be able to see down to the chest wall. The Radiologist, Surgeon and Nurse advised that they did not have any specific guidance in relation to possible radiation-induced sarcoma ,
████████from the Royal Marsden advised in written evidence, that radiation induced sarcomas are increasing in incidence as more primary breast cancer patients are now offered breast conserving surgery with wide local excision and radiotherapy, rather than mastectomy alone (previously there was no radiation). Therefore, in his view the increasing use of radiotherapy leads to increased number of patients developing radiation induced sarcomas. As ████████ said from the Royal Marsden, diagnosis requires the treating clinician to recognise that this is a possibility .
Furthermore, as ████████ advised in his experience the difficulties in diagnosis are that they are sometimes not recognised by primary and secondary care teams who are the first to see the patient .
In evidence the Radiologist confirmed that the Royal College of Radiologists do not have a protocol for patients who have had previous radiotherapy and implant. Furthermore, Nurse Diagnostician confirmed there was no protocol in the ABS Best Practice Diagnostic Guidelines for radiation induced sarcoma where a patient has had an implant.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly communicate required follow-up to families
Wider context from the report “(3) I have concerns regarding the system in place at Ashford Hospital for 2 week follow ups following an aspiration following an initial assessment at the One Stop Clinic. Following the aspiration Mrs Stokes received, the Nurse advised in evidence Mrs Stokes should have had a further review after two weeks, as indicated in the paperwork, but this was not followed through by the hospital and the message was not clearly communicated to the family . This would have allowed for further follow up in case the bulge had increased in size and in pain and could have potentially identified the need to investigate further.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols for first-line investigation of patients with breast implants after radiotherapy
Wider context from the report “(1) I am concerned that there is not any or insufficient guidance available to clinicians in regard to possible radiation induced sarcoma, or first line investigations for patients with breast implants to be able to see down to the chest wall . The Radiologist, Surgeon and Nurse advised that they did not have any specific guidance in relation to possible radiation-induced sarcoma,
████████from the Royal Marsden advised in written evidence, that radiation induced sarcomas are increasing in incidence as more primary breast cancer patients are now offered breast conserving surgery with wide local excision and radiotherapy, rather than mastectomy alone (previously there was no radiation). Therefore, in his view the increasing use of radiotherapy leads to increased number of patients developing radiation induced sarcomas. As ████████ said from the Royal Marsden, diagnosis requires the treating clinician to recognise that this is a possibility.
Furthermore, as ████████ advised in his experience the difficulties in diagnosis are that they are sometimes not recognised by primary and secondary care teams who are the first to see the patient.
In evidence the Radiologist confirmed that the Royal College of Radiologists do not have a protocol for patients who have had previous radiotherapy and implant . Furthermore, Nurse Diagnostician confirmed there was no protocol in the ABS Best Practice Diagnostic Guidelines for radiation induced sarcoma where a patient has had an implant .
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure to complete scheduled two-week follow-up after aspiration
Wider context from the report “(3) I have concerns regarding the system in place at Ashford Hospital for 2 week follow ups following an aspiration following an initial assessment at the One Stop Clinic . Following the aspiration Mrs Stokes received, the Nurse advised in evidence Mrs Stokes should have had a further review after two weeks, as indicated in the paperwork, but this was not followed through by the hospital and the message was not clearly communicated to the family. This would have allowed for further follow up in case the bulge had increased in size and in pain and could have potentially identified the need to investigate further.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Insufficient duration of surveillance for radiation-induced sarcoma after breast cancer
Wider context from the report “(2) I have a concern regarding the current surveillance period of 5 years provided to patients with breast cancer considering the latency period of radiation induced sarcoma is 10 years .
” 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 The organisation cannot comment on Ashford Hospital’s follow-up appointment system.
Verbatim wording from the response “The RCN is unable to comment on the system in place for follow-up appointments at Ashford Hospital. However, we can say that a clear process should be in place for organisation of follow-up appointments. The experience of our members would indicate that there is on occasion a lack of administrative support for nurses undertaking specialist or advanced roles, and whilst we do not know if this was the case at this hospital, it is vital that there are the appropriate staff with the requisite knowledge and skills supported by systems and processes to enable timely follow up and progression of clinical recommendations.” Source location 2024-0436 - Response from RCN
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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 As a non-regulator, individual cases fall outside the organisation’s remit for comment.
Verbatim wording from the response “The Royal College of Nursing (RCN) is the largest nursing union and professional body, we support over half a million nurses, midwives, nursing support workers and students working together to advance our profession. The RCN is not a regulator and therefore does not comment on individual cases. We support the coroner’s concerns regarding lack of guidance and pathways for radiation induced sarcoma and individuals with implants. We support the concern regarding an extension to the surveillance period.” Source location 2024-0436 - Response from RCN
Open published response
13 Jun 2024 Harry Roland Ian Vass · Prevention of Future Deaths report Avon
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Concerns raised 3 Lack of mental health nursing staff awareness that ABD is a medical emergency View source Failure to reliably identify acute behavioural disturbance in vulnerable patients View source Failure to undertake adequate physical-health observations for highly agitated patients 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
Harry Roland Ian Vass · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Harry Roland Ian Vass attended Southmead Hospital on 26 December 2022 with agitation, paranoid thoughts and recent cocaine use, and was later admitted to the Mason Unit. He became unresponsive after vomiting, low oxygen saturations, a high temperature and discolouration of his extremities, and died after transfer back to the emergency department. Concerns included inadequate physical and non-contact observations, and a lack of awareness among mental health nursing staff that acute behavioural disturbance is a medical emergency.
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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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health nursing staff awareness that ABD is a medical emergency
Wider context from the report “• Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health.
• It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency .
• The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters.”
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably identify acute behavioural disturbance in vulnerable patients
Wider context from the report “• Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health.
• It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency.
• The decision as to whether a person has ABD is important , Dr Delaney said that” this group are vulnerable to cardiac arrest ”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters .”
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake adequate physical-health observations for highly agitated patients
Wider context from the report “• Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health .
• It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency.
• The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters.”
” 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 ABD is neither a formal diagnosis nor explicitly embedded in nurses’ professional proficiencies.
Verbatim wording from the response “We agree with Mr Delaney’s statement. However, as stated above, ABD is neither a formal diagnosis nor explicitly embedded in nurses' proficiencies for professional practice.³ The only inferred related proficiency could be:” Source location Response from RCN
Open published response
19 Dec 2022 Mollie Rose Stansfield · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 2 Failure to understand the implementation, significance and effect of Section 5(2) doctors holding power View source Failure to properly complete Section 5(2) Mental Health Act paperwork 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
Mollie Rose Stansfield · 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
Mollie Rose Stansfield, aged 22, died on 10 July 2019 after falling at Princes Quay, Hull, following her discharge from a place of safety under section 136 of the Mental Health Act 1983. The report identified failures at Hull Royal Infirmary to understand and correctly implement section 5(2) of the Mental Health Act 1983, with the relevant paperwork being invalid while Mollie was apparently subject to that section and subsequently absconded.
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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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the implementation, significance and effect of Section 5(2) doctors holding power
Wider context from the report “There was a failure at Hull Royal Infirmary to understand the process of implementing Section 5(2) of the Mental Health act 1983 [MHA] (Doctors Holding Power) as well as general uncertainty about its significance and effect . Mollie absconded from the ward whilst apparently under this section. The paperwork for the implementation of this section of the MHA 1983 was in fact not properly completed and hence invalid. Whilst the Hull & East Yorkshire NHS Trust has taken steps to educate doctors about this power, these were only local measures and I believe that all doctors working in England and Wales should be aware of section 5(2) and nurses of their equivalent power pursuant to section 5(4) of the MHA 1983 and that appropriate awareness and training should be given.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure to properly complete Section 5(2) Mental Health Act paperwork
Wider context from the report “There was a failure at Hull Royal Infirmary to understand the process of implementing Section 5(2) of the Mental Health act 1983 [MHA] (Doctors Holding Power) as well as general uncertainty about its significance and effect. Mollie absconded from the ward whilst apparently under this section. The paperwork for the implementation of this section of the MHA 1983 was in fact not properly completed and hence invalid . Whilst the Hull & East Yorkshire NHS Trust has taken steps to educate doctors about this power, these were only local measures and I believe that all doctors working in England and Wales should be aware of section 5(2) and nurses of their equivalent power pursuant to section 5(4) of the MHA 1983 and that appropriate awareness and training should be given.
” Open source report
11 Mar 2020 Rifky GROSSBERGER · Prevention of Future Deaths report Inner North London
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Concerns raised 3 Lack of accessible safety information for new parents about metal blind cord dangers View source Unavailability of a national leaflet on metal blind cord dangers View source Lack of reminders for midwives and district nurses to warn new parents about metal blind cord dangers 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
Rifky GROSSBERGER · 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
Rifky Grossberger became entangled in a metal blind cord in her cot on 31 July 2019 and died five days later after resuscitation. The principal concern was that her parents were unaware of the danger, and that safety information about blind cords may not be consistently provided to new parents by leaflets, healthcare professionals or other sources.
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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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Lack of accessible safety information for new parents about metal blind cord dangers
Wider context from the report “Before Rifky became entangled in the metal blind cord, her parents were unaware of its potential danger . The instruction leaflet provided with the blinds had long since been discarded and so they did not see this.
I asked Rifky’s mum what would have been the most useful source of warning, and she thought the leaflets she was given after Rifky was born, and also her healthcare professionals .
Professor Powis, I have attempted to locate a national leaflet, but so far unsuccessfully. It occurs to me that you may have input into local leaflets.
████████ the midwives and district nurses who look after new mums and their babies are well placed to offer advice, but may need a reminder to warn of this particular danger.
I appreciate that new parents receive a lot of paperwork and a lot of information generally. That can be overwhelming of course, but I am sure that methods could be devised of delivering such safety advice that would make this situation less likely in the future .
The NHS website would also be a good place to provide this information, though it might not have assisted in this case, as Orthodox Jewish families do not necessarily access the internet.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a national leaflet on metal blind cord dangers
Wider context from the report “Before Rifky became entangled in the metal blind cord, her parents were unaware of its potential danger. The instruction leaflet provided with the blinds had long since been discarded and so they did not see this.
I asked Rifky’s mum what would have been the most useful source of warning, and she thought the leaflets she was given after Rifky was born, and also her healthcare professionals.
Professor Powis, I have attempted to locate a national leaflet, but so far unsuccessfully . It occurs to me that you may have input into local leaflets.
████████ the midwives and district nurses who look after new mums and their babies are well placed to offer advice, but may need a reminder to warn of this particular danger.
I appreciate that new parents receive a lot of paperwork and a lot of information generally. That can be overwhelming of course, but I am sure that methods could be devised of delivering such safety advice that would make this situation less likely in the future.
The NHS website would also be a good place to provide this information, though it might not have assisted in this case, as Orthodox Jewish families do not necessarily access the internet.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Lack of reminders for midwives and district nurses to warn new parents about metal blind cord dangers
Wider context from the report “Before Rifky became entangled in the metal blind cord, her parents were unaware of its potential danger. The instruction leaflet provided with the blinds had long since been discarded and so they did not see this.
I asked Rifky’s mum what would have been the most useful source of warning, and she thought the leaflets she was given after Rifky was born, and also her healthcare professionals.
Professor Powis, I have attempted to locate a national leaflet, but so far unsuccessfully. It occurs to me that you may have input into local leaflets.
████████ the midwives and district nurses who look after new mums and their babies are well placed to offer advice, but may need a reminder to warn of this particular danger .
I appreciate that new parents receive a lot of paperwork and a lot of information generally. That can be overwhelming of course, but I am sure that methods could be devised of delivering such safety advice that would make this situation less likely in the future.
The NHS website would also be a good place to provide this information, though it might not have assisted in this case, as Orthodox Jewish families do not necessarily access the internet.
” 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 Raise awareness of strangulation and suffocation risks among members through professional forums and social media platforms.
Verbatim wording from the response “In considering your report, we have reviewed and strengthened our guidance about the potential risks of strangulation and suffocation on our clinical webpages for Health Visitors, Midwives, School Nurses, Children’s Nurses, Neonatal Nurses and General Practice Nurses. Further to this, we have also brought this matter to the attention of our members through Forums and their social media platforms.” Source location 2020-0070-Response-from-Royal-College-of-Nursing_Redacted-1
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 Review and strengthen clinical webpage guidance on strangulation and suffocation risks for relevant nursing and health visiting professionals.
Verbatim wording from the response “In considering your report, we have reviewed and strengthened our guidance about the potential risks of strangulation and suffocation on our clinical webpages for Health Visitors, Midwives, School Nurses, Children’s Nurses, Neonatal Nurses and General Practice Nurses. Further to this, we have also brought this matter to the attention of our members through Forums and their social media platforms.” Source location 2020-0070-Response-from-Royal-College-of-Nursing_Redacted-1
Open published response
5 Nov 2019 Christopher Byron · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 11 Failure to ensure pharmacists and clinical teams apply consistent ferritin-checking expectations View source Lack of regular independent peer review of coronial autopsy reports and processes View source Lack of a documented and recorded referral process between District Nurses and Tissue Viability Nurses View source Shortage of staff within the Tissue Viability Nurse team View source Failure to produce accurate and satisfactory coronial post-mortem reports View source Inadequate emergency response arrangements for out-patient iron infusions View source Failure to obtain ferritin levels for anaemia management View source Insufficient access to appropriate dressings for severe pressure sores View source Unclear Royal College of Nursing instructions on continuous observation during iron infusions View source Unclear instructions on continuous observation during iron infusions View source Failure to record pharmacist-clinician discussions and advice View source See 8 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
Christopher Byron · 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
Christopher Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.
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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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure pharmacists and clinical teams apply consistent ferritin-checking expectations
Wider context from the report “2. In addition there was no evidence that on the 30th December or the 9th January 2017 the pharmacist checked Mr Byrons ferritin level . The Court heard from the Clinical lead pharmacist that he would expect this to be done. There was a clear difference between the advice and expectations of the pharmacist and the Clinical team .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Nursing; that does not assign responsibility.
PFD Monitor interpretation Lack of regular independent peer review of coronial autopsy reports and processes
Wider context from the report “3. It is noted there is no regular (independent) peer review of coronial autopsy reports and processes in order to maintain consistency of agreed standards, governance and accountability as was advised within the 2006 National Confidential Enquiry into Patient Death and Outcome (NCEPOD) and reiterated within the Hutton review of forensic pathology of England and Wales in 2015.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Lack of a documented and recorded referral process between District Nurses and Tissue Viability Nurses
Wider context from the report “1. The Court heard evidence that since the death of Mr Byron the District Nursing and Tissue Viability Nurses (TVNs) are now managed as part of the Northern Care Alliance and are jointly located. However there is no documented policy for the referring of patients from the District Nurses to the TVNs . “Unofficial” referrals could occur by way of conversations within the office and there is no policy to ensure these are recorded in writing and recorded in the patients notes . The Court heard evidence that such a referral was thought to have occurred in September 2016 but this was not documented anywhere.
2. Likewise if a referral is sent by email there no instruction to staff that such email must be uploaded into the patients records in order for it to be clearly seen by all workers that the patient has been referred.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Shortage of staff within the Tissue Viability Nurse team
Wider context from the report “3. Shortage of staff. One of the reasons there was a lack of continuity in the care of Mr Byron was the shortage of staff and the increased workload on the remaining staff. The Court was advised there remains a shortage of staff within the Tissue Viability Nurse team .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure to produce accurate and satisfactory coronial post-mortem reports
Wider context from the report “1. The quality of the post mortem examination report produced by ████████ was wholly unsatisfactory and proven inaccurate . This meant both the bereaved family and the Trust were initially provided with an inaccurate medical cause of death. As a direct consequence the ability to learn lessons in order to prevent future deaths was not captured in a timely manner. It was not until the Coroner obtained a report from ████████ in 2018 that anaphylaxis was offered as a potential cause of death. Even then, the Court was left having to consider the totality of the evidence and it was not until the inquest that a finding of fact as to the medical cause of death was made.
2. It should be noted the quality of ████████ post mortem practice has been and remains questionable in over 20 Inquests within the North Manchester Coronal area. This is not an isolated case. In this particular case there was clear evidence that the post mortem failings directly impacted on potential lack of clinical learning to prevent future 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Inadequate emergency response arrangements for out-patient iron infusions
Wider context from the report “5. In addition for out-patients who may receive an iron infusion the Court received evidence that they would be handed a buzzer . The Court would question how this would be of use should a patient suffer a cardiac arrest such occurred with Mr Byron. Points 4 and 5 link into the Regulation 28 to the Royal College of Nursing also.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain ferritin levels for anaemia management
Wider context from the report “1. In this case the Trust Guideline ‘Patient Blood Management of Medical Patients’ sets out the Pathway for the Management of Anaemia. In addition to this Trust documents there is NICE guidance for Anaemia – iron deficiency (revised 2018). Both of these documents include as a key factor the obtaining of ferritin levels , albeit the question as to the interpretation of such results will be dependant on the patients presenting condition. On the 30th December 2016 no sample was taken to check the ferritin levels .
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Insufficient access to appropriate dressings for severe pressure sores
Wider context from the report “1. The Court heard evidence that at times there was a lack of appropriate dressings in order to treat Mr Byrons infected pressure sores. The Court heard evidence the District Nurses cannot order more than two weeks worth of dressings for any individual patient and cannot hold extra stock . In Mr Byrons case due to the severity and location of the pressure sores there were times when he used more dressings, especially if they came away from the wounds. This could lead to a shortage and meant him having to wait for dressings . In someone with severe pressures sores the requirement to have access to the appropriate dressings is important. The Court heard this instruction regarding the ordering of dressings is governed by the Clinical Commissioning Group.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Unclear Royal College of Nursing instructions on continuous observation during iron infusions
Wider context from the report “1. In the most recent guidance from the Royal College of Nursing dated May 2019, “Iron Deficiency and Anaemia in Adults” the instruction to nurses is for them to “observe the patient for 30 minutes”. The Court heard evidence from the Divisional Director of Nursing for the Northern Care Alliance who told the Court, in his view this instruction to nurses is unclear . This instruction was felt to be open to interpretation as to whether this means nurses should physically remain with the patient constantly for 30 minutes . If this is what is meant then it was suggested the instruction could be made more specific.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Unclear instructions on continuous observation during iron infusions
Wider context from the report “4. The Court heard the Trust Guideline ‘Patient Blood Management of Medical Patients’ indicated the patient was to be observed for 30 minutes during the administration of the iron infusion. Due to a lack of recording the nurse who administered the iron infusion on the 30th December 2017 could not be identified. The nurse on the 9th January 2017 gave evidence to the Court that this was the first time she had administered an iron infusion and she was advised by the Sister to “treat it as a blood transfusion” whereby his observations were taken before and immediately after commencement of the infusion and observations taken every 15 minutes. Hence Mr Byron was left alone during the administration of the iron infusion. The Court heard the policy was unclear as to whether it meant nurses had to remain with the patient constantly for 30 minutes .
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure to record pharmacist-clinician discussions and advice
Wider context from the report “3. The Court heard of discussions which take place between the Pharmacists and clinicians. These can take place at times when the pharmacist is off the ward. In these circumstances there is no ability for the pharmacist to record such discussions . There was no record anywhere of any discussions on the 30th December 2016 or the 9th January 2017 and any such advice provided, so there was no way of confirming if such conversations had taken place.
” Open source report
28 Mar 2018 Donald Martin · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 2 Failure to know how to deflate patient mattresses in an emergency View source Failure to understand why or when to carry out CPR on a flat surface 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
Donald Martin · 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
Donald Martin, a 96-year-old resident of Langdale Heights Nursing Home with Chronic Obstructive Pulmonary Disease receiving long-term oxygen treatment, was observed struggling to breathe on 14 January 2016 and was pronounced deceased shortly after the ambulance arrived. The court found non-causative deficiencies in the emergency response before the ambulance service arrived. Concerns included whether the nurse in charge understood why or when CPR should be carried out on a flat surface and her lack of knowledge about deflating patient mattresses during an emergency.
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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure to know how to deflate patient mattresses in an emergency
Wider context from the report “Nurse Cecilia Banjoko was the nurse in charge on 14 January 2016. During the course of the inquest she gave evidence that she no longer works at Langdale Heights Nursing Home and is now a nurse at The New Lodge Nursing Home in Mickleover, Derby. She gave evidence that since Mr Martin's death she had attended and completed practical training in relation to basic life support and cardio-pulmonary resuscitation (CPR). However, she also gave evidence that (i) she did not know then and still did not know why the ambulance controller had asked her to move Mr Martin from his bed to the floor prior to the arrival of the ambulance crew and (ii) she did not know how to deflate a patient’s mattress at the time of Mr Martin's death and was still unaware of how to do so .
I am concerned that Nurse Banjoko:
(i) may not understand why or when it appropriate to carry out CPR on a flat service;
(ii) does not know how to deflate patient mattresses in the event of an 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure to understand why or when to carry out CPR on a flat surface
Wider context from the report “Nurse Cecilia Banjoko was the nurse in charge on 14 January 2016. During the course of the inquest she gave evidence that she no longer works at Langdale Heights Nursing Home and is now a nurse at The New Lodge Nursing Home in Mickleover, Derby. She gave evidence that since Mr Martin's death she had attended and completed practical training in relation to basic life support and cardio-pulmonary resuscitation (CPR). However, she also gave evidence that (i) she did not know then and still did not know why the ambulance controller had asked her to move Mr Martin from his bed to the floor prior to the arrival of the ambulance crew and (ii) she did not know how to deflate a patient’s mattress at the time of Mr Martin's death and was still unaware of how to do so.
I am concerned that Nurse Banjoko:
(i) may not understand why or when it appropriate to carry out CPR on a flat service ;
(ii) does not know how to deflate patient mattresses in the event of an emergency.
” 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 Complete basic life support training, including a practical CPR assessment.
Verbatim wording from the response “Ms Banjoko continues to remediate her practice and address any concerns there may have been with her practice at the time of the incident and she continues to undertake mandatory training and has completed basic life support training, including a practical assessment in CPR (enclosed for the Coroner’s attention).” Source location 2018-0166-Response-by-Royal-College-of-Nursing
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 Complete and provide a reflective account addressing CPR procedures, emergency mattress deflation, and the need for a firm surface.
Verbatim wording from the response “Further to the Regulation 28 Report provided to Ms Cecilia Banjoko, please find enclosed a copy of her reflective piece following the Inquest in this matter.” Source location 2018-0166-Response-by-Royal-College-of-Nursing
Open published response
29 Sep 2013 Dorothy Townley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Lack of District Nurse training on treatment of burns View source Failure of District Nurses and the GP to communicate and coordinate wound care visits View source Lack of District Nursing Team knowledge about treatment of burns View source Inadequate detail in wound assessment charts for burns View source Lack of shared understanding between the GP and District Nurses about requesting urgent blood tests 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
Dorothy Townley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Dorothy Townley sustained burns after spilling tea at home on 28 September 2012; the burns became infected and she was admitted to hospital on 11 October. Despite active treatment, she died on 20 October 2012. Concerns included communication between District Nurses and the GP, limited knowledge and training in burn treatment, inadequate wound assessment documentation, and unclear processes for requesting urgent blood tests.
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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Lack of District Nurse training on treatment of burns
Wider context from the report “4. There was a lack of training for District Nurses on the treatment of burns.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Failure of District Nurses and the GP to communicate and coordinate wound care visits
Wider context from the report “1. There was a lack of direct communication between the District Nurses and the GP as to exactly what the deceased’s condition was and what was required on visits. There was no consideration given to carrying out joint visits, no communication as to how Mrs Townley’s wound could be examined if there were no dressings available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Nursing; that does not assign responsibility.
PFD Monitor interpretation Lack of District Nursing Team knowledge about treatment of burns
Wider context from the report “2. There was a lack of knowledge within the District Nursing Team around the treatment of burns.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Inadequate detail in wound assessment charts for burns
Wider context from the report “3. The wound assessment chart did not assist as it was not as detailed as it should be for burns in order to help chart their progress or deterioration.
” 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 Nursing; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding between the GP and District Nurses about requesting urgent blood tests
Wider context from the report “5. There was a lack of understanding between the GP and District Nurses as to how to request urgent blood tests. It was assumed by the GP that his request for a blood test would be treated as urgent and done that day (on 10th); the District Nurses indicated it would only be carried out as ‘urgent’ if requested.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations