Concerns raised 5 Failure to safely secure medication brought into hospital View source Failure to obtain relevant previous inpatient mental health records View source Failure to investigate and respond to complaints View source Failure to ensure patients have appropriate clothing and footwear at discharge View source Failure to provide direct referral to community mental health services for patients without a GP 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
Andrew James AITKEN · 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 Aitken was admitted to hospital on 10 June 2014 after taking a drug overdose, was treated and discharged on 16 June. Two months later he was found dead at home from amitriptyline toxicity, without having accessed mental health care in the meantime. Concerns included the handling of the remaining tablets, failure to seek records of a previous psychiatric admission, lack of direct referral to community mental health services despite him having no GP, and his discharge without clothes or shoes.
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to safely secure medication brought into hospital
Wider context from the report “1. When Mr Aitken was admitted to hospital on 10 June 2014, his girlfriend brought in the remainder of the tablets he had taken, hoping to assist those treating him.
████████ told me that a nurse took the tablets from her, of which there were still many remaining, and simply left them on the hospital bedside cabinet next to Mr Aitken .
” 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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain relevant previous inpatient mental health records
Wider context from the report “2. Mr Aitken had been admitted to Prestwich Hospital Psychiatric Hospital when he was 16 years old. When he was admitted on 10 June 2014, no consideration was given to asking for any record of that inpatient stay .
That was some 14 years earlier and may not have yielded anything useful but, as Mr Aitken was not registered with a general practitioner, it was the only source of history from healthcare professionals.
” 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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate and respond to complaints
Wider context from the report “4. I was told that Mr Aitken was discharged from hospital in gown and socks, with no clothes or shoes.
I understand that East London Trust has now decided to undertake a serious incident review, but I am concerned that ████████ has already written to the Royal London Hospital, has received no response to that letter , and has been told that there is no ongoing investigation into her complaint .
” 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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure patients have appropriate clothing and footwear at discharge
Wider context from the report “4. I was told that Mr Aitken was discharged from hospital in gown and socks, with no clothes or shoes .
I understand that East London Trust has now decided to undertake a serious incident review, but I am concerned that ████████ has already written to the Royal London Hospital, has received no response to that letter, and has been told that there is no ongoing investigation into her complaint.
” 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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide direct referral to community mental health services for patients without a GP
Wider context from the report “3. The junior psychiatrist discharging Mr Aitken did strongly advise him to register with a GP and then to seek referral to mental health services, but it did not occur to her to refer him direct to the community mental health team, given that he had no GP .
” Open source report
Concerns raised 6 Failure to record intentional rounding checks View source Failure to perform neurological observations before discharge View source Failure to complete physiotherapy assessment before discharge View source Failure to communicate pending physiotherapy assessment information View source Failure to record post-fall neurological observations View source Premature issuing of discharge paperwork 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
Irshad ALI · 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
Irshad Ali was admitted to hospital for drainage of ascites, fell unwitnessed on the ward on 25 March 2014, and later returned with a massive head injury. He died six weeks later following a consequent chest infection. Concerns included missing records of intentional rounding and neurological observations, required pre-discharge checks not being completed, and communication problems around his discharge.
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record intentional rounding checks
Wider context from the report “1. The nursing staff should have checked on Mr Ali every two hours through the night, but there was no record of intentional rounding on 24/25 March . There was a record of the night before and a record of the night after, but not the night that Mr Ali fell. The chart appears to have gone missing.
” 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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to perform neurological observations before discharge
Wider context from the report “3. The consultant in charge of Mr Ali’s care stipulated that his junior medical colleagues should perform neurological observations before Mr Ali could be discharged, yet this did not take place .
The sister in charge told me that she asked the registrar if Mr Ali was neurologically stable enough to be discharged, and she said yes.
” 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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete physiotherapy assessment before discharge
Wider context from the report “4. The consultant in charge of Mr Ali’s care also stipulated that Mr Ali should undergo physiotherapy assessment before he could be discharged, yet this did not take place .
The sister in charge told me that she knew about this and she knew that a physiotherapist was going to review Mr Ali that afternoon. However, she did not pass this information on to the nurse who looked after Mr Ali during the sister’s lunch break, nor to Mr Ali’s family.
The nurse said that she did tell Mr Ali’s family he was not ready for discharge, but she gave them the discharge paperwork before she went for lunch and so they assumed he could go.
Both the doctor and the nurse who gave evidence told me that they now think that discharge packs should not be given out until the patient’s discharge is complete.
” 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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate pending physiotherapy assessment information
Wider context from the report “4. The consultant in charge of Mr Ali’s care also stipulated that Mr Ali should undergo physiotherapy assessment before he could be discharged, yet this did not take place.
The sister in charge told me that she knew about this and she knew that a physiotherapist was going to review Mr Ali that afternoon. However, she did not pass this information on to the nurse who looked after Mr Ali during the sister’s lunch break, nor to Mr Ali’s family .
The nurse said that she did tell Mr Ali’s family he was not ready for discharge, but she gave them the discharge paperwork before she went for lunch and so they assumed he could go.
Both the doctor and the nurse who gave evidence told me that they now think that discharge packs should not be given out until the patient’s discharge is complete.
” 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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record post-fall neurological observations
Wider context from the report “2. Though the senior sister looking after Mr Ali on the morning of 25 March assured me that neurological observations were carried out hourly after his fall, there was no record of this . Again, the chart appears to have gone missing.
” 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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation Premature issuing of discharge paperwork
Wider context from the report “4. The consultant in charge of Mr Ali’s care also stipulated that Mr Ali should undergo physiotherapy assessment before he could be discharged, yet this did not take place.
The sister in charge told me that she knew about this and she knew that a physiotherapist was going to review Mr Ali that afternoon. However, she did not pass this information on to the nurse who looked after Mr Ali during the sister’s lunch break, nor to Mr Ali’s family.
The nurse said that she did tell Mr Ali’s family he was not ready for discharge, but she gave them the discharge paperwork before she went for lunch and so they assumed he could go.
Both the doctor and the nurse who gave evidence told me that they now think that discharge packs should not be given out until the patient’s discharge is complete .
” Open source report
Concerns raised 2 Failure to record required patient observations View source Failure to refer patients to critical care when appropriate 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
Gregg O’REILLY · 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
Gregg O’Reilly was admitted as an emergency with dehydration, poor nutritional state, high stoma output, acute kidney injury and a high white cell count. He later developed multi-organ failure and repeated bleeding from his abdominal wound, but did not recover after surgery and critical care admission. The report raised concerns that he was not referred to critical care by 17.01.14 and that no observation records could be found between midnight and 3am before his second bleed and cardiac arrest call.
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record required patient observations
Wider context from the report “Further, although he was on two hourly observations, no record of any observation could be found between midnight on 17.01.14 and 3am on 18.01.14 , when Mr O’Reilly was found to have suffered a second bleed with very low blood pressure, and a cardiac arrest call was made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal London Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients to critical care when appropriate
Wider context from the report “I heard that an opportunity was missed by the medical, ward nursing and critical care nursing outreach teams, to refer Mr O’Reilly to critical care , certainly by 17.01.14. It is unclear whether that would have changed the outcome for him, but it meant that he was not offered optimal care . Given the number of staff who could have made such a referral, it seems that this issue goes further than individual error or lack of understanding . I appreciate that also makes it a big issue to tackle.
” 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