11 Feb 2026 Chloe Angela Ulett · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 9 Failure to routinely measure ammonia levels in adults presenting with behavioural change and confusion View source Lack of guidance on referral pathways for raised ammonia levels View source Failure of RCEM investigation guidance to identify when metabolic screens and ammonia levels are clinically indicated View source Failure to consider ammonia testing nationally, causing risk of delayed diagnosis View source Short diagnostic and treatment window for metabolic disorders presenting with behavioural change and confusion View source Omission of urea cycle and metabolic disorders from RCEM behavioural disturbance risk factors View source Lack of best-practice guidance recommending ammonia testing for undifferentiated acutely confused patients View source Lack of awareness outside inherited metabolic disease teams of postpartum presentation of undiagnosed urea cycle disorders View source Failure to embed RCEM acute behavioural disturbance guidance in adult emergency medicine View source See 6 more concerns
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AI-generated summary
Chloe Angela Ulett · 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
Chloe Angela Ulett died at Birmingham Heartlands Hospital on 28 September 2024 from a previously undiagnosed urea cycle disorder that had been unmasked by giving birth. She developed confusion and excessive drowsiness after childbirth, was initially diagnosed with iron deficiency and discharged, and ammonia testing was delayed until several days later. The principal concerns were that early ammonia testing was not routine, relevant guidance was unclear and not embedded in adult medicine, and there remained a national risk of delayed diagnosis.
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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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely measure ammonia levels in adults presenting with behavioural change and confusion
Wider context from the report “2. There are no identified NICE or BMJ best practice guidelines which currently recommend testing of ammonia levels for undifferentiated acutely presenting confused patients.
3. Nationally, early measurement of ammonia levels in adults presenting to the emergency department and other units for investigation and management of behavioural change and confusion are not routine practice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on referral pathways for raised ammonia levels
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department.
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised . The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure of RCEM investigation guidance to identify when metabolic screens and ammonia levels are clinically indicated
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department.
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated . Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to consider ammonia testing nationally, causing risk of delayed diagnosis
Wider context from the report “9. It was further identified that inherited metabolic disease specialists are aware that a previously undiagnosed urea cycle disorders may be unmasked by giving birth and present for the first time in the post-partum period with symptoms of altered GCS including confusion, excessive drowsiness, seizures but this association is not known outside this speciality even in those caring for women in the post-partum period.
10. Following Miss Ulett's death the University Hospitals of Birmingham NHS Foundation Trust ('UHB') assessed the speciality teams who could encounter patients presenting with altered consciousness due to unmasked previous undiagnosed urea cycle disorder and identified the relevant specialities were emergency medicine, acute medical, intensive care medicine and maternity services.
11. Whilst UHB has done a lot of work internally with the specialities identified to raise awareness of the potential presentation of an unmasked previously undiagnosed urea cycle disorder to an emergency department with acute behavioural disturbance and the need for consideration of ammonia testing at an early stage, there remains a national risk from delay in diagnosis because ammonia testing has not been considered .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Short diagnostic and treatment window for metabolic disorders presenting with behavioural change and confusion
Wider context from the report “1. The window of opportunity to consider and make a diagnosis of a metabolic disorder and institute effective treatment is very short, 24 to 48 hours from the commencement of symptoms , and relies on early measurement of ammonia in an adult presenting with behavioural change and confusion .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Omission of urea cycle and metabolic disorders from RCEM behavioural disturbance risk factors
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department.
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1 , and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of best-practice guidance recommending ammonia testing for undifferentiated acutely confused patients
Wider context from the report “2. There are no identified NICE or BMJ best practice guidelines which currently recommend testing of ammonia levels for undifferentiated acutely presenting confused patients .
3. Nationally, early measurement of ammonia levels in adults presenting to the emergency department and other units for investigation and management of behavioural change and confusion are not routine practice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness outside inherited metabolic disease teams of postpartum presentation of undiagnosed urea cycle disorders
Wider context from the report “9. It was further identified that inherited metabolic disease specialists are aware that a previously undiagnosed urea cycle disorders may be unmasked by giving birth and present for the first time in the post-partum period with symptoms of altered GCS including confusion, excessive drowsiness, seizures but this association is not known outside this speciality even in those caring for women in the post-partum period .
10. Following Miss Ulett's death the University Hospitals of Birmingham NHS Foundation Trust ('UHB') assessed the speciality teams who could encounter patients presenting with altered consciousness due to unmasked previous undiagnosed urea cycle disorder and identified the relevant specialities were emergency medicine, acute medical, intensive care medicine and maternity services.
11. Whilst UHB has done a lot of work internally with the specialities identified to raise awareness of the potential presentation of an unmasked previously undiagnosed urea cycle disorder to an emergency department with acute behavioural disturbance and the need for consideration of ammonia testing at an early stage, there remains a national risk from delay in diagnosis because ammonia testing has not been considered.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to embed RCEM acute behavioural disturbance guidance in adult emergency medicine
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department .
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” 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 Routine ammonia testing is not warranted in all confused patients because hyperammonaemia is a diagnosis of exclusion and sepsis requires priority assessment.
Verbatim wording from the response “Hyperammonaemia is rare but the presentation of those with confusion due to any cause is high in the acute setting. 10-20% of all admissions present with confusion due to a wide variety of issues (National Institute for Health and Care Excellence: Delirium, prevention, diagnosis and management (CG103). London: NICE; 2010 (updated 2019)). Hyperammonaemia remains a diagnosis of exclusion and as such, ammonia levels are not usually in the first bloods sent for a patient, as the primary aim in someone presenting with confusion is to ensure they do not have sepsis. As highlighted by this challenging case, hyperammonaemia remains a diagnosis that should be carefully considered when the cause of acute confusion is unclear.” Source location 2026-0086- Response from Royal College of Physicians
Open published response
5 Dec 2025 Man Yin ‘Anita’ Ng · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 3 Complex and insufficiently streamlined processes for treating aneurysmal subarachnoid haemorrhages View source Variation in the availability of neurointerventional procedures View source Unclear and misaligned overall clinical responsibility for patients with ruptured aneurysms 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
Man Yin ‘Anita’ Ng · 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
Man Yin ‘Anita’ Ng attended hospital with a subarachnoid haemorrhage caused by an aneurysm. Her coiling procedure was delayed while staff sought an available neurointerventional catheter lab and anaesthetist; she suffered a re-rupture shortly before the procedure and died on 22 January 2025. The principal concern was that complex arrangements and unclear overall clinical responsibility for managing ruptured aneurysms may place patients at risk, particularly because of variation in access to neurointerventional procedures.
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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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Complex and insufficiently streamlined processes for treating aneurysmal subarachnoid haemorrhages
Wider context from the report “I am concerned that the processes surrounding the treatment of subarachnoid haemorrhages, arising from aneurysms, are complex and not as streamlined as compared to other treatments.
There is clearly variation in the availability of neurointerventional procedures. This is a nationwide resource issue, which I heard has been recognised and that steps are being taken to address. The specific concern which arises from Anita’s death relates to which clinical team is best placed to have overall responsibility for such patients.
I heard that, traditionally, neurosurgeons would treat these cases but that, increasingly, ruptured aneurysms are treated by interventional radiologists, with input from the neurosurgery team limited to initial referral, investigation and post-procedural care.
However, Anita’s case demonstrates the complexities of this arrangement, which I heard contrasts with the change in practice that has occurred in the treatment of patients who have suffered strokes and also cardiac patients treated by interventional cardiologists (when previously they would have been under the care of cardiothoracic surgeons).
I heard evidence that interventional radiologists do not have admitting rights, which would allow them to have patients admitted to hospital wards and that, as such, patients like Anita would come under the care of the neurosurgical team.
I am concerned that this complex arrangement does not reflect the current management of such patients and places them at risk. Whilst the circumstances in which Anita died were unusual, my concern relates to the overarching manner in which this condition is managed, particularly when compared to thrombectomies.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Variation in the availability of neurointerventional procedures
Wider context from the report “I am concerned that the processes surrounding the treatment of subarachnoid haemorrhages, arising from aneurysms, are complex and not as streamlined as compared to other treatments.
There is clearly variation in the availability of neurointerventional procedures. This is a nationwide resource issue, which I heard has been recognised and that steps are being taken to address. The specific concern which arises from Anita’s death relates to which clinical team is best placed to have overall responsibility for such patients.
I heard that, traditionally, neurosurgeons would treat these cases but that, increasingly, ruptured aneurysms are treated by interventional radiologists, with input from the neurosurgery team limited to initial referral, investigation and post-procedural care.
However, Anita’s case demonstrates the complexities of this arrangement, which I heard contrasts with the change in practice that has occurred in the treatment of patients who have suffered strokes and also cardiac patients treated by interventional cardiologists (when previously they would have been under the care of cardiothoracic surgeons).
I heard evidence that interventional radiologists do not have admitting rights, which would allow them to have patients admitted to hospital wards and that, as such, patients like Anita would come under the care of the neurosurgical team.
I am concerned that this complex arrangement does not reflect the current management of such patients and places them at risk. Whilst the circumstances in which Anita died were unusual, my concern relates to the overarching manner in which this condition is managed, particularly when compared to thrombectomies.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Unclear and misaligned overall clinical responsibility for patients with ruptured aneurysms
Wider context from the report “I am concerned that the processes surrounding the treatment of subarachnoid haemorrhages, arising from aneurysms, are complex and not as streamlined as compared to other treatments.
There is clearly variation in the availability of neurointerventional procedures. This is a nationwide resource issue, which I heard has been recognised and that steps are being taken to address. The specific concern which arises from Anita’s death relates to which clinical team is best placed to have overall responsibility for such patients.
I heard that, traditionally, neurosurgeons would treat these cases but that, increasingly, ruptured aneurysms are treated by interventional radiologists, with input from the neurosurgery team limited to initial referral, investigation and post-procedural care.
However, Anita’s case demonstrates the complexities of this arrangement, which I heard contrasts with the change in practice that has occurred in the treatment of patients who have suffered strokes and also cardiac patients treated by interventional cardiologists (when previously they would have been under the care of cardiothoracic surgeons).
I heard evidence that interventional radiologists do not have admitting rights, which would allow them to have patients admitted to hospital wards and that, as such, patients like Anita would come under the care of the neurosurgical team.
I am concerned that this complex arrangement does not reflect the current management of such patients and places them at risk. Whilst the circumstances in which Anita died were unusual, my concern relates to the overarching manner in which this condition is managed, particularly when compared to thrombectomies.
” 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 Existing pathways should remain unchanged, with patients unsuitable for coiling remaining under neurosurgical care.
Verbatim wording from the response “We would strongly support that the pathways remain unchanged and given both complications and the original ruptured aneurysm if coiling is not feasible remain under the care of the neurosurgeons.” Source location Response from Royal College of Physicians
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The patient did not experience a delay associated with transfer because the treating hospital had a dedicated neurosurgical unit.
Verbatim wording from the response “The RCP notes the matters of concern raised in this report, particularly the concerns about the processes surrounding the treatment of subarachnoid haemorrhage. Many of those who present with such a clinical problem in the acute hospital setting will be picked up by emergency departments and transferred to the neurosurgeons for further management directly. In this case, Mrs Ng, who presented to a centre with a dedicated neurosurgical unit (at Coventry and Warwickshire hospital), did not have the delay which can be associated with transfer from centres without neurosurgery on site. However, the Royal College of Physicians wish to make clear that in the case where there is no neurosurgical unit, for example, a district general hospitals, pathways should be in place and do exist for transfers to be facilitated as quickly as possible for patients to receive specialist treatment.” Source location Response from Royal College of Physicians
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 Neurosurgeons and linked multidisciplinary teams are best placed to manage subarachnoid haemorrhage patients and determine treatment.
Verbatim wording from the response “In asking for our guidance as to who is best to manage patients with this condition, we would state that the neurosurgeons and linked MDT are best placed to manage these patients, especially due to the fact that not all centres have a dedicated neurosurgical service or neuro-interventional service and the importance of such patients being managed by these specialist teams rather than delay treatment options. This enables appropriate protocols to be in place for the safe and effective use of such services and offers the best outcomes for patients. This said, unfortunately the nature of subarachnoid haemorrhages is such that re-rupture is unpredictable, including primary rupture, and even the best neurosurgeons who manage the complex aneurysms cannot predict whether someone may rupture before intervention can be done in a safe and timely manner.” Source location Response from Royal College of Physicians
Open published response
14 Oct 2025 Paula Doreen Hughes · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Failure to prevent concurrent prescriptions of paracetamol-containing drugs View source Lack of robust mechanisms to mitigate confirmation bias and encourage professional curiosity View source Lack of a mechanism for consistently recording pre-admission over-the-counter medications View source Insufficient guidance for accurate and consistent assessment of the ACVPU confusion element View source Lack of guidance or policy for deciding when virtual reviews can replace face-to-face reviews View source Lack of a robust process for managing therapeutic excess and potential toxicity View source Risk of loss or dilution of prescribing safety nets during electronic system changes 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.
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AI-generated summary
Paula Doreen Hughes · 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
Paula Doreen Hughes was admitted to hospital after a fall and received paracetamol in excess of the recommended dose because paracetamol was prescribed alongside co-codamol. The overdose was not recognised until she had developed fulminant acute liver failure, and timely treatment was not provided. The principal concerns included preventing duplicate paracetamol prescriptions and administration, recognising and managing therapeutic excess, accurately assessing confusion, recording over-the-counter medicines, mitigating confirmation bias, and providing guidance for virtual patient reviews.
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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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent concurrent prescriptions of paracetamol-containing drugs
Wider context from the report “1. In respect of preventing concurrent prescriptions of paracetamol containing drugs and otherwise preventing prescribing errors resulting in therapeutic excess of paracetamol (NHSE, RPS, Cerner, MHRA, LGT)
(1) NHSE, RPS, Cerner, MHRA
I consider that the risk of concurrent prescriptions of paracetamol containing drugs is of wider national concern.
The Cerner prescribing system offers a duplicate checking functionality that is not a standard feature. It is hard stop and can be overridden and was not adopted by the LGT when the system was introduced. All the healthcare professionals were aware that co-codamol contained paracetamol and should not be prescribed with paracetamol. However, the 2 prescribing doctors failed to recognise that Mrs Hughes was already prescribed a paracetamol containing drug. 2 nurses failed to recognise they were administering 2 paracetamol containing drugs. A pharmacist failed to identify the concurrent prescriptions during reconciliation.
(2) LGT
LGT’s response to the incident was swift and commendable. A hard stop was introduced to the electronic prescribing system which eliminated concurrent prescriptions of paracetamol containing drugs. Further refinements of the system significantly reduced therapeutic excesses of paracetamol based on weight, which had been identified as an issue when investigating Mrs Hughes’ death. However, it is my understanding that consideration is being given to changing the electronic record and prescribing system. My concern is that during any move to a new system, the safety nets introduced by the Trust will be diluted or lost.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of robust mechanisms to mitigate confirmation bias and encourage professional curiosity
Wider context from the report “5. Trust approach to mitigating against confirmation bias and encouraging professional curiosity (LGT)
Confirmation bias and a lack of professional curiosity were significant features in Mrs Hughes’ being administered two paracetamol containing drugs at the same time and in not investigating whether she had received a therapeutic excess and suffered consequential harm. I have found that the Trust does not have robust mechanism for mitigating against confirmation bias and encouraging professional curiosity.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for consistently recording pre-admission over-the-counter medications
Wider context from the report “4. Mechanism for recording over the counter medications taken prior to attendance at the Emergency Department (LGT)
This concern has arisen out of my finding that Mrs Hughes had taken an over the counter (OTC) drug containing paracetamol before her admission to hospital but that this had not been recorded as part of her medication history. The Trust’s Medicines Reconciliation Policy requires that patients should be asked about OTCs. The Trust relies on individual clinical practice. There is no mechanism to ensure that pre-admission OTCs are consistently recorded such that the risk of therapeutic excess of paracetamol (or other drugs available OTC) in those circumstances continues to exist.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance for accurate and consistent assessment of the ACVPU confusion element
Wider context from the report “3. The assessment of the ACVPU score (LGT, RCP, NHSE)
This concern has arisen out of the fact that Mrs Hughes was scored as alert when she was confused. Confusion would have added a score of 3 to her NEWS2 score and would have resulted in an earlier escalation of her condition. I heard that confusion is not always easy to identify and that the signs can be subtle.
(1) LGT
The Trust provided training materials relating to detection and management of deteriorating patients. There was minimal guidance on how to accurately assess the ACVPU score and the confusion element in particular. There remains a tangible risk that the ACVPU score will continue to be assessed inconsistently, with new episodes of confusion continuing to be missed.
(2) NHSE, RCP
I consider that consistent and accurate assessment of the ACVPU element of the NEWS2 score is likely to a matter of wider concern. This concern is being brought to the attention of NHSE and the RCP as I consider that they have the power to support healthcare professionals to ensure consistent and accurate scoring of confusion.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance or policy for deciding when virtual reviews can replace face-to-face reviews
Wider context from the report “6. Trust policy on managing virtual patient reviews (LGT)
This concern has arisen out of the fact that Mrs Hughes had been reviewed virtually rather than face to face a resident doctor on the morning before she became unwell. The Trust has no guidance or policy on virtual reviews. I was told that this is a matter of clinical judgment. The absence of any guidance to help a still relatively inexperienced resident doctor decide when they can dispense with a face-to-face review is a circumstance that creates a risk that future deaths may occur.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust process for managing therapeutic excess and potential toxicity
Wider context from the report “2. Management of therapeutic excess if it has not been prevented (LGT)
This issue has arisen from the finding that once the concurrent prescription had been identified, there had no attempt to consider whether there had been a therapeutic excess and whether Mrs Hughes had suffered harm. The Trust’s response to the incident focused on prevention. It did not consider the adequacy of the clinical response once the overdose had been identified. The Trust relies on information sharing of learning from incidents and thereafter places reliance on individual clinical practice. I received no evidence of a robust process for ensuring a consistent clinical response to the management of therapeutic excess and the potential for toxicity.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Risk of loss or dilution of prescribing safety nets during electronic system changes
Wider context from the report “1. In respect of preventing concurrent prescriptions of paracetamol containing drugs and otherwise preventing prescribing errors resulting in therapeutic excess of paracetamol (NHSE, RPS, Cerner, MHRA, LGT)
(1) NHSE, RPS, Cerner, MHRA
I consider that the risk of concurrent prescriptions of paracetamol containing drugs is of wider national concern.
The Cerner prescribing system offers a duplicate checking functionality that is not a standard feature. It is hard stop and can be overridden and was not adopted by the LGT when the system was introduced. All the healthcare professionals were aware that co-codamol contained paracetamol and should not be prescribed with paracetamol. However, the 2 prescribing doctors failed to recognise that Mrs Hughes was already prescribed a paracetamol containing drug. 2 nurses failed to recognise they were administering 2 paracetamol containing drugs. A pharmacist failed to identify the concurrent prescriptions during reconciliation.
(2) LGT
LGT’s response to the incident was swift and commendable. A hard stop was introduced to the electronic prescribing system which eliminated concurrent prescriptions of paracetamol containing drugs. Further refinements of the system significantly reduced therapeutic excesses of paracetamol based on weight, which had been identified as an issue when investigating Mrs Hughes’ death. However, it is my understanding that consideration is being given to changing the electronic record and prescribing system. My concern is that during any move to a new system, the safety nets introduced by the Trust will be diluted or lost.
” Open source report
Concerns raised 2 Failure of prescribing software to trigger alerts for the interaction between amitriptyline, paroxetine and ivabradine View source Lack of prescriber understanding of the interaction between ivabradine, amitriptyline and paroxetine 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
Chloe Elizabeth Burgess · 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
Chloe Elizabeth Burgess was found deceased at home on 8 September 2023. The report states that interactions between amitriptyline, paroxetine and ivabradine, together with an episode of sleep apnoea, contributed to severe cardiac arrhythmia and sudden cardiac death. The principal concerns were that the potential dangers of this medication combination were not widely appreciated and did not trigger alerts in prescribing software, and that prescribers of ivabradine should have a full understanding of the potential interaction.
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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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure of prescribing software to trigger alerts for the interaction between amitriptyline, paroxetine and ivabradine
Wider context from the report “The inquest heard evidence that the potential dangers of the combination of amitriptyline, paroxetine and ivabradine is not widely appreciated and does not trigger an alert on the prescribing software used in primary care or by pharmacists . The potential dangers related to a failure to metabolise amitriptyline which can, incrementally, lead to toxicity.
I am also concerned that those prescribing ivabradine should have a full understanding of the potential interaction with amitriptyline and paroxetine.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of prescriber understanding of the interaction between ivabradine, amitriptyline and paroxetine
Wider context from the report “The inquest heard evidence that the potential dangers of the combination of amitriptyline, paroxetine and ivabradine is not widely appreciated and does not trigger an alert on the prescribing software used in primary care or by pharmacists. The potential dangers related to a failure to metabolise amitriptyline which can, incrementally, lead to toxicity.
I am also concerned that those prescribing ivabradine should have a full understanding of the potential interaction with amitriptyline and paroxetine .
” 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 Prescribers are responsible for understanding medicine interactions and applying appropriate caution or monitoring rather than relying solely on software alerts.
Verbatim wording from the response “It is the role of all prescribers to understand the overarching mechanisms of action of medicines they may prescribe, and where similar actions occur by more than one medicine, or might exacerbate pathology in individual patients, particular caution or monitoring should be instituted. It is important that they do not rely on prescribing software, but use recognised reference materials.” Source location Response from Royal College of Physicians
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 Prescribing software alerts are determined by independent commercial providers, which choose the reference materials informing alert content.
Verbatim wording from the response “The Royal Pharmaceutical Society, as joint publishers of the BNF, have advised that pharmacokinetic (drug metabolism) interactions are included within the BNF, but that all theoretical compound effects of combinations of medications through their mode of action cannot be included. Furthermore, prescribing software for primary care and pharmacies is provided by independent commercial organisations, who will choose which reference materials they use to inform alerts. This software and its application is currently not regulated.” Source location Response from Royal College of Physicians
Open published response
24 Feb 2025 Pamela Anne Marking · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners View source Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery View source Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients View source Unavailability of promptly accessible suction for aspiration during rapid sequence induction View source Failure to inform patients and families that Physician Associates are not medically qualified View source Lack of public understanding of the Physician Associate role View source Lack of guidance on TIVA dosing and timing for rapid sequence induction View source Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction View source Failure to prevent Physician Associates undertaking roles outside their competency View source Lack of regulated scope-of-practice guidance and recognised training for Physician Associates View source See 7 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
Pamela Anne Marking · 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
Pamela Anne Marking was admitted with abdominal symptoms, was diagnosed with a nosebleed by a Physician Associate and discharged without medical review or direct medical supervision. She later returned with small bowel obstruction caused by an incarcerated femoral hernia and aspirated feculent fluid during induction of anaesthesia for emergency surgery, subsequently dying from respiratory failure and sepsis. The concerns included the Physician Associate’s role, supervision and scope of practice, and the absence of updated guidance for rapid sequence induction, TIVA and airway protection.
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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners
Wider context from the report “1. The term ‘Physician Associate’ is misleading to the public
Mrs Marking’s son was under the mistaken belief that the Physician Associate was a doctor by this title in circumstances where no steps were taken by the Emergency Department or the Physician Associate to explain or clearly differentiate their role from that of medically qualified practitioners .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery
Wider context from the report “6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery
Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Physicians; that does not assign responsibility.
PFD Monitor interpretation Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients
Wider context from the report “5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates
Whilst there were discussions with the ‘supervising’ consultant the Physician Associate was effectively acting independently in the diagnosis, treatment, management and discharge of Mrs Marking without independent oversight by a medical practitioner . This gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Unavailability of promptly accessible suction for aspiration during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to inform patients and families that Physician Associates are not medically qualified
Wider context from the report “3. The right of patients and family to seek a second opinion
The lack of public knowledge that a Physician Associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a Physician Associate rather than a medically qualified doctor.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of public understanding of the Physician Associate role
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on TIVA dosing and timing for rapid sequence induction
Wider context from the report “7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI
Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4).
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation . After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent Physician Associates undertaking roles outside their competency
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of regulated scope-of-practice guidance and recognised training for Physician Associates
Wider context from the report “4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate
A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in an abdominal examination in a patient who was unable to give a proper clinical history because of short term memory loss. No evidence was presented that the management of Mrs Marking was subject to a reflective practice review. Given their limited training and in the absence of any national or local recognised hospital training for Physician Associates once appointed , this gives rise to a concern they are working outside of their capabilities .
” 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 Publish interim guidance requiring physician associates to explain their roles, supervision and educational or clinical background to patients, families, carers and colleagues.
Verbatim wording from the response “The RCP published interim guidance on titles and introductions for PAs in December 2024, in which we were clear that ‘PAs must clearly explain their role to patients, their families and carers, as well as colleagues and supervisors, and provide details of their educational and clinical supervision when required.’” Source location Response from Royal College of Physicians
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 Clearly communicate that physician associates are not doctors and must not replace doctors.
Verbatim wording from the response “Working with our fellows and members, the RCP will continue to actively campaign to limit the pace and scale of roll-out of PAs in the NHS until we are reassured that there are safe systems in place for PA deployment. We have repeatedly made clear that PAs are not doctors, and they cannot and must not replace doctors. We have also called on the UK government and the NHS to develop and publish an evidence-base and evaluation framework around the introduction of PAs. This should be a priority, and we are working with the RCP Patient Safety Committee to consider what more we can do to support this agenda.” Source location Response from Royal College of Physicians
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 Campaign with fellows and members to limit the pace and scale of physician-associate rollout until safe deployment systems are established.
Verbatim wording from the response “Working with our fellows and members, the RCP will continue to actively campaign to limit the pace and scale of roll-out of PAs in the NHS until we are reassured that there are safe systems in place for PA deployment. We have repeatedly made clear that PAs are not doctors, and they cannot and must not replace doctors. We have also called on the UK government and the NHS to develop and publish an evidence-base and evaluation framework around the introduction of PAs. This should be a priority, and we are working with the RCP Patient Safety Committee to consider what more we can do to support this agenda.” Source location Response from Royal College of Physicians
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 interim guidance for physician associates working in medical specialties.
Verbatim wording from the response “We agree with this and the RCP has written published interim guidance for physician associates working in the medical specialties.” Source location Response from Royal College of Physicians
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The right to seek a second opinion should be addressed locally.
Verbatim wording from the response “This would be addressed at a local level, but we fully support the implementation of Martha’s Rule to enable families to ask for a second opinion when they are worried about a relative’s acute deterioration. In addition, we are clear that PAs should not be making decisions independently, particularly around discharge in patients in an emergency or undifferentiated setting.” Source location Response from Royal College of Physicians
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 Recipients with anaesthesia expertise are best placed to respond to concerns 6, 7 and 8.
Verbatim wording from the response “This letter has also been addressed to recipients with expertise in anaesthesia, who may be best placed to respond to concerns 6, 7 and 8.” Source location Response from Royal College of Physicians
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 The GMC is responsible for regulating physician associates, while national system leaders should develop their scope of practice and supervision framework.
Verbatim wording from the response “The RCP believes that PAs should be working to nationally-agreed guidelines and relying on local guidelines only risks inconsistency, or at worst no agreed guidelines at all. The GMC is now responsible for regulation, but our understanding is that regulation will need to be supported by national guidelines to provide a clear framework for assessment. We would also welcome clarity of PA clinical competency at qualification; we note passing the PA exit exam is not synonymous with competency and ability in a clinical setting.” Source location Response from Royal College of Physicians
Open published response
Concerns raised 5 Allergy plans failing to distinguish lip swelling as a potential anaphylaxis symptom View source Insufficient education of parents and patients on safe AAI use when in doubt View source Failure to recognise inability to swallow as a sign of anaphylaxis in dental settings View source Lack of sufficiently clear distinction between anaphylactic and mild reactions View source Unavailability of AAI stock in chemists for emergencies 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
Hannah Enola Ayamo Jacobs · 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
Hannah Enola Ayamo Jacobs, aged 13, developed anaphylactic symptoms after being served a dairy hot chocolate despite her reported dairy allergy and later died following cardiac arrest. The concerns included dental staff not recognising excessive salivation as inability to swallow and a sign of anaphylaxis, possible misunderstanding of symptoms by her mother, and the availability and use of adrenaline auto-injectors during shortages.
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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Allergy plans failing to distinguish lip swelling as a potential anaphylaxis symptom
Wider context from the report “• The other symptom Hannah demonstrated was swelling of her lips which is listed on allergy plans as a mild to moderate symptom and thus provided a false sense of reassurance to her mother that cetirizine was what she needed.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Insufficient education of parents and patients on safe AAI use when in doubt
Wider context from the report “• The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of what constitutes an anaphylactic reaction as opposed to a mild reaction, and the education of parents and patients of the safety of using AAIs (adrenaline auto injectors) IF IN DOUBT .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise inability to swallow as a sign of anaphylaxis in dental settings
Wider context from the report “• The evidence at the inquest referred to allergy action plans discussed in the healthcare settings and given to parents and patients. Hannah displayed what appeared to be excessive salivation at the dentist which her paediatric consultant (who gave evidence) said, with the benefit of hindsight was actually a manifestation of her inability to swallow. This is a sign of anaphylaxis This was not recognised by dental staff as an inability to swallow and thus of anaphylaxis.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficiently clear distinction between anaphylactic and mild reactions
Wider context from the report “• The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of what constitutes an anaphylactic reaction as opposed to a mild reaction , and the education of parents and patients of the safety of using AAIs (adrenaline auto injectors) IF IN DOUBT.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Unavailability of AAI stock in chemists for emergencies
Wider context from the report “• I was made aware there had been a shortage of AAI at the time but a vial of adrenaline was available at the chemist. However, it takes time to draw up. I am not sure if (assuming no national shortage) all chemists have AAI in stock for emergencies .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with professional bodies to agree and support allergy standards of care and education.
Verbatim wording from the response “The RCP will work with Royal College of Paediatrics and Child Health, Royal College of Pathologists, British Society for Immunology – Clinical Immunology Professional Network, British Society for Allergy and Clinical Immunology, dental and pharmacy professional groups, to agree and support standards of care and education related to allergy. This will include updating standards for allergy accreditation, including the adoption of the BSACI adult allergy action plan where many of the aspects related to this case are addressed including carrying adrenaline autoinjectors, and difficulty in swallowing is an indication for the use of adrenaline.” Source location Response from Royal College of Physicians
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update allergy accreditation standards, including adoption of the BSACI adult allergy action plan.
Verbatim wording from the response “The RCP will work with Royal College of Paediatrics and Child Health, Royal College of Pathologists, British Society for Immunology – Clinical Immunology Professional Network, British Society for Allergy and Clinical Immunology, dental and pharmacy professional groups, to agree and support standards of care and education related to allergy. This will include updating standards for allergy accreditation, including the adoption of the BSACI adult allergy action plan where many of the aspects related to this case are addressed including carrying adrenaline autoinjectors, and difficulty in swallowing is an indication for the use of adrenaline.” Source location Response from Royal College of Physicians
Open published response
1 Aug 2024 Derryck Lynn CROCKER · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 5 Failure to recognise and report air embolism cases View source Delays in recognising air embolism View source Delays in treating air embolism View source Lack of nationally consistent air embolism awareness training across relevant specialties View source Lack of knowledge and training on recognising air embolism following invasive procedures 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
Derryck Lynn CROCKER · 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
Derryck Crocker underwent a CT-guided lung biopsy on 3 May 2023 and subsequently developed a cerebral air embolism, deteriorated, and died on 10 May 2023. The principal concerns were limited recognition of air embolism following invasive procedures, insufficient training and awareness across medical specialties, and delays in recognition and treatment that may increase the likelihood of death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and report air embolism cases
Wider context from the report “2. I also heard evidence that in areas where enhanced training has been provided, due to adverse incidents such as Mr Crocker’s death, there appears to be increased numbers of cases. This leads to the question of whether the lack of knowledge means that such cases are missed and unreported and the rise is due to greater awareness.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Delays in recognising air embolism
Wider context from the report “3. I heard that, in some cases, with timely treatment, outcome may be significantly improved, but that with delayed recognition and therefore delayed treatment, death is more likely .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Delays in treating air embolism
Wider context from the report “3. I heard that, in some cases, with timely treatment, outcome may be significantly improved, but that with delayed recognition and therefore delayed treatment, death is more likely .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally consistent air embolism awareness training across relevant specialties
Wider context from the report “4. I heard evidence that there is ongoing work with the Royal College of Radiologists to provide them training on this issue, but that training was needed to ensure that all other specialties who may encounter this condition have raised awareness nationally .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge and training on recognising air embolism following invasive procedures
Wider context from the report “1. I heard evidence that there is a lack of understanding of the signs and symptoms of an air embolism and the risk of this following any invasive procedure . I heard evidence that nationwide and across all levels of specialism and seniority, there was a lack of knowledge and that air embolism is not something that is routinely taught as part of the training of doctors . While it is accepted that this is rare, it is life threatening if not appropriately treated swiftly.
” Open source report
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 Physicians; 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 Physicians; 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 Physicians; 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 Physicians; 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 Physicians; 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 Physicians; 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 Physicians; 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 position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specific discharge timing recommendations cannot be made because appropriate timing depends on multiple patient-specific variables.
Verbatim wording from the response “• For guidance on longer term monitoring of people with epilepsy, and safe discharge timing it is not possible to provide guidance on this that suits all patients with epilepsy as it depends on many variables. The ABN therefore do not feel that it would be appropriate to make specific recommendations regarding timing for discharge. Many patients are now enrolled in patient-initiated follow-up schemes (or equivalent) rather than being fully discharged. Fewer routine reviews may aid seeing people when most needed.” Source location Response from Royal College of Physicians
Open published response
Concerns raised 1 Unavailability of timely out-of-hours in-person cardiologist assessment for patients with suspected cardiac problems 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
Charlotte Burton · 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
Charlotte Burton, who was 40 and recently postpartum, returned to hospital on 27 November 2020 with shortness of breath and coughing up blood. She later deteriorated, suffered a cardiac arrest and died from acute left ventricular failure associated with cardiomyopathy, morbid obesity and pre-eclampsia. The report identified delayed recognition and treatment of likely diastolic heart failure, delayed escalation, and limited out-of-hours access to cardiology assessment as concerns.
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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Unavailability of timely out-of-hours in-person cardiologist assessment for patients with suspected cardiac problems
Wider context from the report “1. The evidence indicates that there is a nationwide shortage of suitably trained Cardiologists and that, particularly in District General Hospital setting, this means that out of hours there is no provision for patients presenting with suspected cardiac problems to be assessed in person by a Cardiologist . The system is therefore reliant upon doctors of different specialities or cardiac nurses recognising the condition and the need for contact with specialist at a different Trust . This still does not allow for in person assessment unless there is a transfer which is not always possible due to the severity of the condition or cannot be achieved in a suitable timescale and this represents an ongoing risk of future deaths.
” Open source report
15 Nov 2023 Calogero Di Blasi · Prevention of Future Deaths report Avon
View report summary
Concerns raised 3 Failure of specialty teams to communicate investigation information and share results in a timely manner View source Failure of 2-week urgent cancer pathway timeframes to include investigation reporting and referring-clinician review View source Insufficient breadth of endoscopist training for recognition of less frequently occurring lesions 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
Calogero Di Blasi · 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
Calogero Di Blasi was referred for possible stomach and bowel cancer and underwent investigations including endoscopies and a CT scan. During a further endoscopy, a gastric varix was mistaken for an abnormal area and biopsied, causing a massive bleed; he died on 1 December 2022. The concerns included communication failures between specialist teams, insufficient timeframes for reviewing investigations on the urgent cancer pathway, and limitations in endoscopist training for recognising less common lesions.
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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure of specialty teams to communicate investigation information and share results in a timely manner
Wider context from the report “(1) That one of the teams caring for Mr Di Blasi was completely unaware of the input from another specialty team , despite both referrals being made under the 2-week urgent referral pathway. The lack of communication between these teams meant that timely sharing of results did not occur . Even the very knowledge of the fact that a CT scan had taken place would have alerted the endoscopist to check those results, and it is likely that the second endoscopy would not have gone ahead. I understand this to be a national issue and is likely to apply to other investigations being carried out.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure of 2-week urgent cancer pathway timeframes to include investigation reporting and referring-clinician review
Wider context from the report “(2) That the reporting timeframes on the 2-week urgent cancer pathway referral does not take into account timeframes for reporting investigative procedures or subsequent review by the referring clinicians .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Insufficient breadth of endoscopist training for recognition of less frequently occurring lesions
Wider context from the report “(3) The current training for Endoscopists for JAG certification requires the performance of 200 endoscopies. However, these tend to focus on the clinician’s area of specialty and therefore there is a danger that lesion recognition will be limited and insufficient to ensure that endoscopists are able to recognise less frequently occurring lesions . With the need for an increasing number of endoscopists, action should be taken.
” 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.
×
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 Physicians; 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 Physicians; 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 Physicians; 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 Physicians; 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 Physicians; 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 Physicians; 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
×
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 Urge national and local government to tighten regulation of pollution-generating activity and improve public information.
Verbatim wording from the response “12. Most important is government action to reduce air pollution, particularly more regulation of pollution generating activity. There needs to be a particular focus on initiatives that reduce the exposure of women, children, older people, and people in lower socioeconomic groups, in which ethnic minorities are overrepresented.” Source location 2021-0113-Response-from-Royal-College-of-Physicians-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add questions on air pollution to the examinations administered by the Royal College of Physicians.
Verbatim wording from the response “5. The curriculum does not specifically mention air pollution, but it does reference the GMC’s General Professional Capabilities, which do include Health Promotion and Illness Prevention. We accept that there needs to be better understanding by doctors of the impacts of air pollution on health so we will” Source location 2021-0113-Response-from-Royal-College-of-Physicians-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with relevant specialist societies to decide how to increase physicians’ knowledge of air-pollution health impacts.
Verbatim wording from the response “5. The curriculum does not specifically mention air pollution, but it does reference the GMC’s General Professional Capabilities, which do include Health Promotion and Illness Prevention. We accept that there needs to be better understanding by doctors of the impacts of air pollution on health so we will” Source location 2021-0113-Response-from-Royal-College-of-Physicians-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review local delivery of the postgraduate internal medicine curriculum in light of air-pollution health impacts.
Verbatim wording from the response “5. The curriculum does not specifically mention air pollution, but it does reference the GMC’s General Professional Capabilities, which do include Health Promotion and Illness Prevention. We accept that there needs to be better understanding by doctors of the impacts of air pollution on health so we will” Source location 2021-0113-Response-from-Royal-College-of-Physicians-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and actively promote resources helping medical professionals understand air pollution and discuss exposure reduction with patients and families.
Verbatim wording from the response “6. There is lots of information available about the impacts of air pollution and the medical community does produce its own reports and events. The RCP and RCPCH 2016 report Every Breath You Take and its 2018 update, for example, were widely read and are still referenced and discussed. But we need to do more to communicate the large amount of scientific evidence available as it makes the case for why medical practitioners need to communicate with patients.” Source location 2021-0113-Response-from-Royal-College-of-Physicians-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities are responsible for communicating local pollution scores and considering air pollution in housing allocation decisions.
Verbatim wording from the response “17. Local authorities have an important role to play, not least in communicating local pollution scores and explaining what they mean to the community. This may include recommending that certain groups do not go out at times when pollution is particularly high, avoid particular roads or areas, and don’t open windows at certain times. Local authorities also have a role in making sure air pollution is a factor in housing allocation decisions.” Source location 2021-0113-Response-from-Royal-College-of-Physicians-Redacted
Open published response
13 Apr 2021 ANN COLES · Prevention of Future Deaths report Surrey
View report summary
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.
×
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 Physicians; 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
×
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 and local shared care guidelines are sufficient for safe amiodarone monitoring; new monitoring and reporting systems are not required.
Verbatim wording from the response “Having reviewed the detail, the RCP would recommend that no new systems of monitoring and reporting are required for the prescription of amiodarone but that strict adherence to existing national NICE and local shared care guidelines will provide for safe and monitored practice.” Source location 2021-0101-Response-from-Royal-College-of-Physicians-Redacted
Open published response
1 Dec 2020 Peter James Michael Unsworth · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to document received specialist advice and confirm understanding View source Failure to confirm and record specialist advice View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter James Michael Unsworth · 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
Peter James Michael Unsworth had a history of deep vein thromboses and was taking long-term anticoagulant medication before a right hip replacement. After developing an infected hip and undergoing surgery, his anticoagulant dose was reduced following haematological advice that was not recorded in writing; he subsequently developed pulmonary emboli and died at home on 29 July 2018. The principal concern was that the lack of written records may have led to a misunderstanding of the advice given and its significance.
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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to document received specialist advice and confirm understanding
Wider context from the report “The evidence showed that:
1. The advice provided by the Consultant Haematologist related to a very complex medical situation. It was not recorded in writing. The Consultant Orthopaedic surgeon did not record it in the patient’s records nor email his understanding of the advice to the Consultant Haematologist for confirmation of what he understood the advice to be.
2. The Consultant Haematologist did not confirm her advice in writing or make any record of the advice given.
3. As a consequence, there may have been a misunderstanding of the basis on which the advice was sought and/or given, and of the import of the advice.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm and record specialist advice
Wider context from the report “The evidence showed that:
1. The advice provided by the Consultant Haematologist related to a very complex medical situation. It was not recorded in writing. The Consultant Orthopaedic surgeon did not record it in the patient’s records nor email his understanding of the advice to the Consultant Haematologist for confirmation of what he understood the advice to be.
2. The Consultant Haematologist did not confirm her advice in writing or make any record of the advice given.
3. As a consequence, there may have been a misunderstanding of the basis on which the advice was sought and/or given, and of the import of the advice.
” 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 Highlight the absence of standards verifying verbally provided clinical advice accuracy to the Professional Record Standards Board.
Verbatim wording from the response “As members of the Professional Record Standards Board (PRSB) we advise on elements of record standards. Following a review with PRSB the recording of advice is covered by GMC guidance, however standards to confirm the accuracy of that advice if it is given verbally is not currently covered in any standard. We have highlighted this as a member of PRSB. In response to learning from the CoViD 19 pandemic and the increase in the use of remote advice have proposed that standards are developed with respect to what elements of remote advice should be documented to ensure effectiveness and prevent harm. Where electronic records exist then this becomes much easier to implement as it is visible to both parties. We continue to advocate for the introduction of integrated electronic record systems within the NHS to enable this.” Source location 2020-0267-Response-from-Royal-College-of-Physicians-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Propose developing standards specifying which elements of remote clinical advice should be documented to ensure effectiveness and prevent harm.
Verbatim wording from the response “As members of the Professional Record Standards Board (PRSB) we advise on elements of record standards. Following a review with PRSB the recording of advice is covered by GMC guidance, however standards to confirm the accuracy of that advice if it is given verbally is not currently covered in any standard. We have highlighted this as a member of PRSB. In response to learning from the CoViD 19 pandemic and the increase in the use of remote advice have proposed that standards are developed with respect to what elements of remote advice should be documented to ensure effectiveness and prevent harm. Where electronic records exist then this becomes much easier to implement as it is visible to both parties. We continue to advocate for the introduction of integrated electronic record systems within the NHS to enable this.” Source location 2020-0267-Response-from-Royal-College-of-Physicians-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue advocating for integrated electronic record systems within the NHS to support safer recording and verification of clinical advice.
Verbatim wording from the response “As members of the Professional Record Standards Board (PRSB) we advise on elements of record standards. Following a review with PRSB the recording of advice is covered by GMC guidance, however standards to confirm the accuracy of that advice if it is given verbally is not currently covered in any standard. We have highlighted this as a member of PRSB. In response to learning from the CoViD 19 pandemic and the increase in the use of remote advice have proposed that standards are developed with respect to what elements of remote advice should be documented to ensure effectiveness and prevent harm. Where electronic records exist then this becomes much easier to implement as it is visible to both parties. We continue to advocate for the introduction of integrated electronic record systems within the NHS to enable this.” Source location 2020-0267-Response-from-Royal-College-of-Physicians-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specific advice to physicians on recording and verifying clinical advice falls outside the organisation’s role and is covered by GMC guidance.
Verbatim wording from the response “The matter of concern in your notice is of the recording and verifying of clinical advice given between clinicians. Whilst the Royal College of Physicians does not give specific advice to Physicians on this matter this is covered under GMC Good Medical Practice Duties of a Doctor which states Clinical records should include: the decisions made and actions agreed, and who is making the decisions and agreeing the actions.” Source location 2020-0267-Response-from-Royal-College-of-Physicians-Redacted
Open published response
9 Oct 2019 James Frankish · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure of professionals caring for people with Pica to understand its health risks View source Lack of national or professional guidance on identification, assessment and management of Pica and its risks View source Lack of national or professional guidance for monitoring bezoar development in people with Pica 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
James Frankish · 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 Frankish died at Beeches Residential Home after vomiting plant material and expelling a hard plant mass from his stomach into his oesophagus, causing sudden obstruction. The principal concerns were that professionals and care staff did not fully understand or manage the dangers of Pica, and that national or professional guidance was lacking on identifying, assessing and managing Pica and monitoring for bezoar development.
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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure of professionals caring for people with Pica to understand its health risks
Wider context from the report “(1) Professionals who cared for James did not understand how dangerous Pica can be , ie that it carries significant health risks, including the development of a bezoar . This included the GP, Paediatrician, Psychiatrist, Speech and language therapist, Clinical Psychologist.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of national or professional guidance on identification, assessment and management of Pica and its risks
Wider context from the report “(2) That there is no national or professional guidance about identification, assessment and management of Pica , with no guidance about how best to understand and manage risk in this condition
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of national or professional guidance for monitoring bezoar development in people with Pica
Wider context from the report “(3) That there is no national or professional guidance for monitoring for the possible development of a bezoar in an individual who has Pica .
” Open source report
12 Jun 2018 Rita Taylor · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Inadequate clinical documentation for care continuity View source Lack of consultant understanding of appropriate hyponatraemia management View source Failure of the serious incident report to fulfil its learning and accuracy obligations View source Failure to obtain appropriate specialist assistance for hyponatraemia management View source Failure to complete specialist consultation for hyponatraemia management View source Failure to follow recommended hyponatraemia monitoring and treatment guidelines View source Failure to create a coherent plan for managing diabetes insipidus and related fluid balance View source Failure to apply appropriate treatment for increasing serum potassium levels View source Lack of meaningful documentation in hospital notes View source Failure to establish a management plan for hyponatraemia 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
Rita 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
Rita Taylor was admitted to hospital with severe hyponatraemia in the context of diabetes insipidus and a pituitary adenoma, and died on 15 August 2017 after developing central pontine myelinolysis. The principal concerns were failures to appropriately monitor and manage her sodium levels and diabetes insipidus, including omission of desmopressin, inadequate fluid-balance assessment, insufficient documentation, and lack of a coherent management plan.
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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical documentation for care continuity
Wider context from the report “6. The documentation throughout Mrs Taylor’s admission until transfer to the high dependency unit was inadequate with no record of assessment or a coherent management plan in place to ensure appropriate care and continuity of that care for succeeding physicians to consider or to follow .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of consultant understanding of appropriate hyponatraemia management
Wider context from the report “4. The apparent lack of understanding of the appropriate management of hyponatraemia by consultants whose care Mrs Taylor was under , despite two emergency consultant physicians having a specialist interest in endocrinology. Whilst some attempt was made to contact St George’s hospital this was not successfully followed through to assist them in their 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure of the serious incident report to fulfil its learning and accuracy obligations
Wider context from the report “7. As was acknowledged in Court, the SI report did not fulfil its obligations and it was agreed that it would be extensively re-written and re-presented to HM Coroner’s Court to more accurately reflect the circumstances of Mrs Taylor’s death and the learning points required to assist in preventing any 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain appropriate specialist assistance for hyponatraemia management
Wider context from the report “1. The failure to appropriately manage Mrs Taylor’s hyponatraemia by the on call consultant physician on the 31st July 2017 on the grounds that it was not his sphere of expertise. No contact was considered or made to someone who may have been able to assist leaving Mrs Taylor to languish overnight with no management plan in place and a lack of any meaningful documentation in her hospital notes.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to complete specialist consultation for hyponatraemia management
Wider context from the report “4. The apparent lack of understanding of the appropriate management of hyponatraemia by consultants whose care Mrs Taylor was under, despite two emergency consultant physicians having a specialist interest in endocrinology. Whilst some attempt was made to contact St George’s hospital this was not successfully followed through to assist them in their 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to follow recommended hyponatraemia monitoring and treatment guidelines
Wider context from the report “2. The failure, at any time between the 31st July 2017 and 5th August 2017 to follow the national recommended guidelines for the management and treatment of hyponatraemia, in particular the need to measure serum sodium regularly and to limit the rate of rise of serum sodium to prevent complications.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to create a coherent plan for managing diabetes insipidus and related fluid balance
Wider context from the report “3. The failure, at any time between the 31st July 2017 until the 6th August 2017 to create a coherent plan for the management of Mrs Taylors medical problems resulting in the failure to assess fluid balance or to reintroduce desmopressin , given a known diagnosis of diabetes insipidus on a background of a pituitary adenoma.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to apply appropriate treatment for increasing serum potassium levels
Wider context from the report “5. The failure of an emergency consultant physician with an interest in endocrinology to understand that giving intravenous fluids with potassium is not an appropriate method to increase serum potassium levels, more so as Mrs Taylor at that time could eat and drink normally.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of meaningful documentation in hospital notes
Wider context from the report “1. The failure to appropriately manage Mrs Taylor’s hyponatraemia by the on call consultant physician on the 31st July 2017 on the grounds that it was not his sphere of expertise. No contact was considered or made to someone who may have been able to assist leaving Mrs Taylor to languish overnight with no management plan in place and a lack of any meaningful documentation in her hospital notes .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to establish a management plan for hyponatraemia
Wider context from the report “1. The failure to appropriately manage Mrs Taylor’s hyponatraemia by the on call consultant physician on the 31st July 2017 on the grounds that it was not his sphere of expertise. No contact was considered or made to someone who may have been able to assist leaving Mrs Taylor to languish overnight with no management plan in place and a lack of any meaningful documentation in her hospital notes.
” Open source report
8 Jun 2016 Peter Seale · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Failure to ensure continued follow-up of patients with pleural plaques View source Lack of national guidance for follow-up and monitoring of patients with pleural plaques 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
Peter Seale · 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
Peter Seale had occupational asbestos exposure, pleural plaques identified in 2011, and a persistent cough in 2013, but no further tests were conducted before he was diagnosed with terminal lung cancer in 2015. The principal concern was the absence of national guidance for follow-up and monitoring of patients with pleural plaques, creating inconsistent approaches and a risk of patients being lost to follow-up where earlier diagnosis or treatment might be possible.
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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure continued follow-up of patients with pleural plaques
Wider context from the report “1. There is no national guidance in relation to the follow-up and monitoring of patients with pleural plaques. Medical opinion is split on the issue leading to inconsistency of approach. There is a risk that patients will be ‘lost to follow-up’ in cases where action could be taken to afford early/earlier diagnosis/treatment and thus prevent death.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for follow-up and monitoring of patients with pleural plaques
Wider context from the report “1. There is no national guidance in relation to the follow-up and monitoring of patients with pleural plaques. Medical opinion is split on the issue leading to inconsistency of approach. There is a risk that patients will be ‘lost to follow-up’ in cases where action could be taken to afford early/earlier diagnosis/treatment and thus prevent death.
” Open source report
23 Oct 2015 Hireiti Kufletsion · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Inadequate frequency of anti-factor Xa review for pregnant women with mechanical valves View source Failure of clinicians managing pregnant women with mechanical heart valves to understand the thrombosis risk and anticoagulation implications View source Insufficient clexane dosing for pregnant women with mechanical valves 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
Hireiti Kufletsion · 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
Hireiti Kufletsion died at Queen Elizabeth Hospital Birmingham on 20 November 2014 from thrombosis of a mechanical mitral valve during the first trimester of pregnancy. The report identified failures to adequately investigate the valve, seek specialist cardiology advice and prescribe adequate doses of clexane, with concerns that pregnant women with mechanical heart valves may be at risk from insufficient anticoagulation and inadequate clinical understanding of the associated thrombosis risk.
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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Inadequate frequency of anti-factor Xa review for pregnant women with mechanical valves
Wider context from the report “(1) In giving evidence ████████ stated that from time to time she does see at her Obstetric/Cardiac clinic pregnant patients with mechanical valves who have had their warfarin changed to clexane at other hospitals in the region on too low a dose of clexane (i.e. not a twice daily 60mg/kg dose). Likewise she is aware that review of anti-factor Xa may not be arranged to occur with adequate frequency (once a week) . Therefore pregnant women with mechanical valves may be at risk from being prescribed insufficient doses of clexane with insufficient review of their anti-factor Xa .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure of clinicians managing pregnant women with mechanical heart valves to understand the thrombosis risk and anticoagulation implications
Wider context from the report “(2) It was apparent from evidence given by clinicians at the Birmingham Heartlands Hospital that they did not understand the extent and gravity of the increased risk of thrombosis to pregnant women with mechanical heart valves and this affected the course of investigations into the deceased’s condition ultimately resulting in a delay in diagnosis until it was too late. Whilst this issue has now been brought to the full attention of all departments within the Birmingham Heartlands Hospital, it is reasonable to assume that there are haematologists, cardiologists and obstetricians without specialist cardio-obstetric knowledge across the country that do not appreciate the implications during pregnancies of patients with a mechanical heart valve for anti-coagulation therapy but maybe involved in the management and care of such patients.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Insufficient clexane dosing for pregnant women with mechanical valves
Wider context from the report “(1) In giving evidence ████████ stated that from time to time she does see at her Obstetric/Cardiac clinic pregnant patients with mechanical valves who have had their warfarin changed to clexane at other hospitals in the region on too low a dose of clexane (i.e. not a twice daily 60mg/kg dose) . Likewise she is aware that review of anti-factor Xa may not be arranged to occur with adequate frequency (once a week). Therefore pregnant women with mechanical valves may be at risk from being prescribed insufficient doses of clexane with insufficient review of their anti-factor Xa.
” Open source report
25 Jul 2014 Clare Serena Anke COOPER · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 14 Insufficiently detailed EDS referral information about low sodium and blood results View source Failure to consider chemical pathology flagging of particularly concerning results View source Lack of a national protocol for assessing seriously ill eating-disorder patients for an organic basis View source No established GP practice system for recognition, assessment and management of electrolyte abnormalities View source Lack of GP routine vital sign monitoring when weight loss is a concern View source Insufficient reinforcement of excluding an organic basis before psychiatric or psychological labelling View source Lack of a documented list of potential diagnoses for exclusion at eating-disorder triage View source Lack of hospital or GP notes available to the post-mortem pathologist View source Failure to robustly assess presenting signs and symptoms and consider or exclude organic causes View source Lack of understanding of hyponatraemia causes, investigation thresholds and required investigations View source Insufficient communication from referral agents to the eating disorder service View source Poor GP documentation View source Insufficiently robust EDS eating-disorder triage proforma for considering and excluding organic causes View source Insufficiently clear published guidance on the causes, investigation and treatment of low blood sodium View source See 11 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
Clare Serena Anke COOPER · 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
Clare Serena Anke Cooper, a young adult, developed weight loss, lassitude, dizziness, nausea, difficulty eating and an intermittently low blood sodium level before dying after a cardiorespiratory arrest and hospital admission. The inquest concluded that she died from the consequences of undiagnosed Addison’s disease and an Addisonian crisis. Principal concerns included inadequate assessment and documentation in primary care, failure to investigate the low sodium and possible physical causes, insufficient eating-disorder service triage processes, and inadequate information available for the post-mortem examination.
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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Insufficiently detailed EDS referral information about low sodium and blood results
Wider context from the report “6. Insufficiently detailed referral letter to EDS (mentioning ‘low sodium’ but not accompanied with a copy of the blood results ) and an opportunity was lost for its significance to be considered
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to consider chemical pathology flagging of particularly concerning results
Wider context from the report “4. No established system for recognition, assessment and management of electrolyte abnormalities within the GP practice and/or consideration of the chemical pathology service to ‘flag-up’ particularly concerning results .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of a national protocol for assessing seriously ill eating-disorder patients for an organic basis
Wider context from the report “8. The lack of a national protocol for assessing patients seriously ill with an eating disorder with the possibility of detecting individuals with an organic basis for the condition .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation No established GP practice system for recognition, assessment and management of electrolyte abnormalities
Wider context from the report “4. No established system for recognition, assessment and management of electrolyte abnormalities within the GP practice and/or consideration of the chemical pathology service to ‘flag-up’ particularly concerning results.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of GP routine vital sign monitoring when weight loss is a concern
Wider context from the report “3. Lack of GP routine vital sign monitoring e.g. heart rate, blood pressure and weight measurement when weight loss is a concern with a lost opportunity to assess the severity of weight loss.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Insufficient reinforcement of excluding an organic basis before psychiatric or psychological labelling
Wider context from the report “10. The need to highlight this case nationally to clarify published guidance with regard to the causes, investigation and treatment of low blood sodium and to reinforce the importance of excluding an organic basis of an illness before labelling the condition a psychiatric or psychological disorder .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of a documented list of potential diagnoses for exclusion at eating-disorder triage
Wider context from the report “7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of hospital or GP notes available to the post-mortem pathologist
Wider context from the report “9. Lack of hospital or GP notes available for the pathologist undertaking the post mortem to facilitate a greater opportunity for clinic-pathological correlation in deaths which are unascertained and a higher level of suspicion to explore rare causes of unexpected death, especially 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to robustly assess presenting signs and symptoms and consider or exclude organic causes
Wider context from the report “2. Lack of evidence of a robust assessment of presenting signs and symptoms with a presumption of a psychological/psychiatric problem without considering or excluding an organic cause .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of hyponatraemia causes, investigation thresholds and required investigations
Wider context from the report “5. Lack of understanding of the underlying causes of hyponatraemia (consistently or intermittently low) and the level below which will require further investigation, and the investigations that should be carried out , particularly in circumstances when there is no obvious cause of the low sodium.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication from referral agents to the eating disorder service
Wider context from the report “7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Poor GP documentation
Wider context from the report “1. Poor GP documentation
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust EDS eating-disorder triage proforma for considering and excluding organic causes
Wider context from the report “7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Insufficiently clear published guidance on the causes, investigation and treatment of low blood sodium
Wider context from the report “10. The need to highlight this case nationally to clarify published guidance with regard to the causes, investigation and treatment of low blood sodium and to reinforce the importance of excluding an organic basis of an illness before labelling the condition a psychiatric or psychological disorder.
” Open source report
3 Mar 2014 Kirabo Kiwanuka · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Lack of clarity about the appropriate care setting and staffing model for physically ill psychiatric patients View source Lack of agreement about when physician referral or senior medical review is required View source Unavailability of timely physician assessment for acutely ill psychiatric-facility patients View source Lack of senior professional agreement about NMS diagnostic criteria View source Failure to involve family in best-interests decisions for sectioned patients lacking capacity View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kirabo Kiwanuka · 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
Kirabo Kiwanuka, a 28-year-old woman with bipolar disorder, died on 11 June 2011 after developing tachycardia, tachypnoea, pyrexia and markedly raised creatinine kinase during psychiatric treatment. The inquest recorded sudden unexpected death in a patient treated with multiple drugs, while NMS could not be confirmed or excluded as a contributory factor. Concerns included uncertainty about diagnosing and managing NMS, whether patients with physical illness in psychiatric facilities should receive medical review or be transferred, and limited family involvement in treatment decisions.
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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the appropriate care setting and staffing model for physically ill psychiatric patients
Wider context from the report “2. There is lack of clarity about whether acutely manic patients in a psychiatric facility with physical illness should receive domiciliary visits from physicians and medical care in the psychiatric facility or be transferred to a medical facility, where psychiatric staff attend and visit.
She was not examined by a physician when she developed abnormal vital signs. At the time it appears that there was no facility for a physician from the neighbouring hospital to be called out for a medical opinion, although this is currently being explored by SLAM and KCH and is included in a draft protocol. When are patients best under the care of a medical and when a psychiatric ITU? How are Trusts to know what is the optimal model of care?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of agreement about when physician referral or senior medical review is required
Wider context from the report “1. There is lack of senior professional agreement about the criteria needed for diagnosis of NMS, or the need for referral to physicians , even in retrospect
Doctors did not agree whether atypical NMS exists and whether in the absence of rigidity cases should be managed differently. In particular a psychiatrist considered psychiatrists were better at care of NMS in their ITU, despite there not being facilities for cardiac monitoring or frequent blood gas analysis, as recommended by the expert psychiatrist, whilst my expert physician simply did not think she needed intensive medical care. There was even disagreement whether a medical registrar opinion or consultant was required . How are junior staff to know what is optimal 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Unavailability of timely physician assessment for acutely ill psychiatric-facility patients
Wider context from the report “2. There is lack of clarity about whether acutely manic patients in a psychiatric facility with physical illness should receive domiciliary visits from physicians and medical care in the psychiatric facility or be transferred to a medical facility, where psychiatric staff attend and visit.
She was not examined by a physician when she developed abnormal vital signs . At the time it appears that there was no facility for a physician from the neighbouring hospital to be called out for a medical opinion , although this is currently being explored by SLAM and KCH and is included in a draft protocol. When are patients best under the care of a medical and when a psychiatric ITU? How are Trusts to know what is the optimal model of care?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of senior professional agreement about NMS diagnostic criteria
Wider context from the report “1. There is lack of senior professional agreement about the criteria needed for diagnosis of NMS , or the need for referral to physicians, even in retrospect
Doctors did not agree whether atypical NMS exists and whether in the absence of rigidity cases should be managed differently . In particular a psychiatrist considered psychiatrists were better at care of NMS in their ITU, despite there not being facilities for cardiac monitoring or frequent blood gas analysis, as recommended by the expert psychiatrist, whilst my expert physician simply did not think she needed intensive medical care. There was even disagreement whether a medical registrar opinion or consultant was required. How are junior staff to know what is optimal 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to involve family in best-interests decisions for sectioned patients lacking capacity
Wider context from the report “3. Where a patient lacks capacity and is under section, the involvement of the family in determining her best interests is required but here it was limited and yet they had concerns about the risks of treatment.
The parents were not given the opportunity to contribute their views to the decision to administer Acuphase , but decisions had to be taken in situations of acute disturbance. What is the role of each of psychiatrists, physicians and next of kin in reaching critical care decisions for sectioned patients with acute medical and psychiatric problems?
” Open source report
13 Feb 2014 Professor John Elfed Davies · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Failure to provide information about relevant support agencies to clinicians subject to investigative processes View source Failure to recognise adverse psychological effects in clinicians subject to investigative processes View source Lack of psychological support for clinicians subject to investigative processes View source Failure to facilitate appropriate on-ward referral for clinicians subject to investigative processes View source Failure to assess and identify suicidal or other self-harming behaviour in clinicians subject to investigative processes View source Failure to use appropriate language and tone in written communications with clinicians subject to investigative processes 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.
×
AI-generated summary
Professor John Elfed Davies · 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
Professor John Elfed Davies, aged 71, was found deceased in his hotel room on 10 June 2013 with self-inflicted incised wounds to his neck and multiple stab wounds to his chest. The inquest concluded that he took his own life, and a note indicated that GMC proceedings were playing on his mind. The principal concern was that doctors undergoing GMC investigations may experience unrecognised and unsupported adverse psychological effects, including suicidal or other self-harming behaviour.
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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to provide information about relevant support agencies to clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies , and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise adverse psychological effects in clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Lack of psychological support for clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported .
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to facilitate appropriate on-ward referral for clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral .
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and identify suicidal or other self-harming behaviour in clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications, the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” 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 Physicians; that does not assign responsibility.
PFD Monitor interpretation Failure to use appropriate language and tone in written communications with clinicians subject to investigative processes
Wider context from the report “This is the second death of a doctor that has come before me over the last 2 years where a GMC investigation into the doctor’s practise has been found to play a part.
I am concerned that clinicians who are subject to such investigative processes are suffering adverse psychological effects which may be unrecognised and unsupported.
Consideration should be given to the language and tone of written communications , the provision of information about relevant support agencies, and the assessment and identification of suicidal or other self harming behaviour by the relevant body and the facilitation of appropriate on-ward referral.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations