13 May 2025 Rose Annie Harfleet · Prevention of Future Deaths report Surrey
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Concerns raised 4 Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities View source Lack of guidance for managing children with profound disabilities in hospital settings View source Failure to recognise and act on parents’ ongoing concerns about children on hospital wards View source Failure to routinely offer learning disability liaison nurse support in the emergency department View source See 1 more concern
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AI-generated summary
Rose Annie Harfleet · 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
Rose Annie Harfleet, aged 12, died in hospital on 30 January 2024 after presenting with abdominal pain and vomiting, later identified as a caecal volvulus causing intestinal obstruction and bowel ischaemia. The report raised concerns about failures to recognise and respond to her deterioration, obtain and act on information from her mother, provide appropriate monitoring and surgical review, and offer learning disability liaison support. It also identified a lack of guidance for managing and consulting with children with profound disabilities in hospital settings.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely obtain and listen to parents’ or guardians’ information about children with profound disabilities
Wider context from the report “2. Guidelines - consultation with parents and guardians of children with profound disabilities within a hospital setting
Rose’s mother was devoted to Rose and was very able to advocate on Rose’s behalf as well as being best placed to provide the vital information about her signs and symptoms given Rose was unable to do this for herself. The importance of obtaining this information was not understood by the paediatric consultant who took no history from Rose’s mother and underestimated the severity of her signs and symptoms. The consequence of this was that Rose’s voice – through her mother as her advocate – was not heard and she was not therefore able to actively participate in the care and management that was provided to Rose, the corollary of which resulted in poor clinical decision making which contributed to Rose’s death. This gives rise to a concern that by not listening to parents or guardians as a matter of course leads to discrimination of disabled children.
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing children with profound disabilities in hospital settings
Wider context from the report “1. The management of children with profound disabilities within a hospital setting
Rose was a deeply loved child who brought great joy to her mother, wider family and all that knew her. During the inquest hearing no national or local guidance was forthcoming to assist medical and nursing staff, within a conventional hospital setting, to appropriately manage patients such as Rose who had a global developmental delay and was wholly reliant on her mother to advocate on her behalf . This gives rise to a concern that this omission adversely impacts the care that patients such as Rose receive.
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and act on parents’ ongoing concerns about children on hospital wards
Wider context from the report “3. Nursing and Medical care on the ward
In the absence of local and national guidelines, the importance of listening and responding to Rose’s mothers ongoing concerns about her daughter when she was transferred to the ward were not recognised by the nursing and medical staff and consequently not acted upon thereby contributing to Rose’s death. There appears to be a prevailing culture that in the absence of a patient being able to explain their symptoms themselves the voice of the parent or guardian is not given the significance it should be for the most vulnerable in a hospital setting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely offer learning disability liaison nurse support in the emergency department
Wider context from the report “4. LeDeR Role
Rose’s admission was during the working week, yet there was no consideration or offer given to Rose or her mother during her time in the Emergency Department to being introduced to a learning Disability Liaison Nurse . This led to Rose’s mother being unsupported during this admission or for a nursing professional to be able to liaise and advocate for Rose and her mother with medical and nursing staff in the emergency department. This again gives rise to a concern that patients such as Rose and her mother are adversely impacted on the care that they receive in the absence of local and national guidelines that this should be routinely available and offered as a matter of course.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a Learning Disabilities and Autism policy with emergency admission guidance and requirements for carer involvement.
Verbatim wording from the response “The Trust has a Learning Disabilities and/or Autism Policy to Support Children and Adults with Learning Disability and/or Autism. This has been developed in accordance with other national and local guidelines, including the Mental Capacity Act 2005, Learning from lives and deaths – People with a learning disability and autistic people (LeDeR) policy (2021), NICE NG93 mental capacity, reasonable adjustments and quiet areas, NG11 restraint, Autism Spectrum Disorder in Adults; Diagnosis and Management – Clinical Guide CG142 (NICE 2016), NHS LD&A Programme 2025 Digital flagging and hospital passports and the Equality Act (2010). Specifically the Trust policy includes an emergency admission flow chart and information about supporting carers and engaging with them in decision making including care and interventions.” Source location Response from Royal Surrey County Hospital NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement Martha’s Rule across adult and paediatric services, addressing its three delivery metrics for patient, family, carer and staff escalation.
Verbatim wording from the response “The Trust is not however aware of any specific national guidance on consultation with the parents and carers of children with profound disabilities although the Trust recognises that this is an essential part of good clinical practice. Whilst not specifically related to children with profound disabilities, the Trust is aware of Martha’s Rule, and have been selected to be part of Phase 2 for implementing this. Work has commenced to address the three metrics for delivery for adults and children.” Source location Response from Royal Surrey County Hospital NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind emergency-department staff to contact the Learning Disability Nurse during working hours for support to staff, patients and families.
Verbatim wording from the response “The CYP Learning Disabilities and Autism Nurse Specialist works Monday – Friday, 08:00 – 16:00. Rose arrived in the Emergency Department on Monday 29th January and an initial assessment was undertaken at 13:14. Rose was then checked by an Emergency Doctor at 16:27. Very sadly, Rose passed away before the CYP Learning Disability Nurse returned on Tuesday 30th January, when the CYP Learning Disability Nurse provided support to Rose’s family. There was potentially an opportunity for the CYP Learning Disability Nurse to have been contacted by the Emergency Department team following Rose’s arrival at 13.14 and prior to the clerking by the Emergency Doctor. The Emergency Department team have been reminded of the presence of the Learning Disability Nurse during working hours and that they can be contacted to help support staff, patients and their families.” Source location Response from Royal Surrey County Hospital NHS Foundation Trust
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5 Sep 2022 Stephen WELLS · Prevention of Future Deaths report West Sussex
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Concerns raised 5 Lack of progress in reviewing or renegotiating the inter-Trust Service Level Agreement View source Ongoing firewall problems between the two Trusts causing reliance on email rather than automatic electronic systems View source Insufficient clarity about key contacts during inter-provider transfers between SASH and RSFT View source Lack of clarity for GPs about where to raise concerns regarding hospital or tertiary-care treatment View source Insufficient guidance or refresher training for hospital doctors on use of the relevant Datix system View source See 2 more concerns
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Stephen WELLS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Wells was treated for colon cancer with liver metastases, but after liver surgery he received no further contact or oncology follow-up for one year because communication and referral processes between two NHS trusts failed. He later developed widespread liver and lung metastases and died at home on 4 October 2021. The report raises concerns about inter-provider referrals, tracking systems, communication between trusts, use of the Datix system, and clarity over patients’ key contacts.
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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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of progress in reviewing or renegotiating the inter-Trust Service Level Agreement
Wider context from the report “b) I also heard evidence from SASH that they would not have expected Mr Wells to be transferred back to them after the liver surgery as further chemotherapy was needed. Conversely, RSFT were unable to explain why Mr Wells did not remain on the Somerset Cancer Registry (SCR) tracking system following discharge and the MDT discussion on 10 August 2020. I was told that the safety net to avoid a cancer patient such as Mr Wells failing to receive further treatment is an inter-provider transfer (IPT) to ensure the responsibility for care is further transferred. In this case, a local process of consultant-to- consultant referrals, in other words a workaround, had evolved and both the hardcopy letter between doctors and an email from the CNS to two separate doctor’s secretaries had failed resulting in no further appointment being made. It was accepted that the communication failure was not identified in a timely manner and that communication systems between both Trusts had blurred with the suggestion that these could be clarified by a renegotiation of the Service Level Agreement (SLA). I was provided with a copy of the current SLA dated 1 January 2015 and note that the particulars state the contract term was 36 months with an end date of 31 December 2017. Given the importance of good systems of communication between Trusts and the IPT system I remain concerned about:
i. the lack of progress made in reviewing/renegotiating the SLA bearing in mind the difficulties in this case were drawn to the attention of the Trusts in September 2021.
ii. an ongoing firewall problem between the two Trusts as this places a current reliance on email rather than automatic electronic systems especially given the failure of emails in this case to secure a much-needed appointment.
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ongoing firewall problems between the two Trusts causing reliance on email rather than automatic electronic systems
Wider context from the report “b) I also heard evidence from SASH that they would not have expected Mr Wells to be transferred back to them after the liver surgery as further chemotherapy was needed. Conversely, RSFT were unable to explain why Mr Wells did not remain on the Somerset Cancer Registry (SCR) tracking system following discharge and the MDT discussion on 10 August 2020. I was told that the safety net to avoid a cancer patient such as Mr Wells failing to receive further treatment is an inter-provider transfer (IPT) to ensure the responsibility for care is further transferred. In this case, a local process of consultant-to- consultant referrals, in other words a workaround, had evolved and both the hardcopy letter between doctors and an email from the CNS to two separate doctor’s secretaries had failed resulting in no further appointment being made. It was accepted that the communication failure was not identified in a timely manner and that communication systems between both Trusts had blurred with the suggestion that these could be clarified by a renegotiation of the Service Level Agreement (SLA). I was provided with a copy of the current SLA dated 1 January 2015 and note that the particulars state the contract term was 36 months with an end date of 31 December 2017. Given the importance of good systems of communication between Trusts and the IPT system I remain concerned about:
i. the lack of progress made in reviewing/renegotiating the SLA bearing in mind the difficulties in this case were drawn to the attention of the Trusts in September 2021.
ii. an ongoing firewall problem between the two Trusts as this places a current reliance on email rather than automatic electronic systems especially given the failure of emails in this case to secure a much-needed appointment.
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient clarity about key contacts during inter-provider transfers between SASH and RSFT
Wider context from the report “c) I heard evidence that Mr Wells was told his key contact in SASH was a named Clinical Nurse Specialist. When his care transferred to RSFT, witnesses expected his key contact to be changed to a CNS based within the St Luke’s Cancer Centre in Guildford. During the inquest I asked to whom the CNS was at RSFT and following enquiries learnt that the St Luke’s staff believed the key contact was the SASH CNS. I remain concerned that there is insufficient clarity for both patients and staff when there is an IPT from SASH to RSFT and vice versa .
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity for GPs about where to raise concerns regarding hospital or tertiary-care treatment
Wider context from the report “a) I heard evidence that Mr Wells GP wrote two urgent letters to the RSFT consultant oncologist and HPB surgeon dated 22 September 2021 raising concerns that the patient had heard nothing further after the liver surgery in September 2020. These letters were sent to the East Surrey hospital by the GP. I heard evidence that both consultants hold clinics in two East Surrey hospitals as well as within their own Trust area. Principally the letters were about lack of treatment for a cancer patient and I heard evidence during the inquest that the RSFT witness assisting the court on governance & risk issues did not know the doctors had received the letters and presumably were not logged on the Datix system thereby raising concerns regarding:
i. whether additional guidance may be appropriate for GPs to know where to raise concerns about patient treatment in hospital or tertiary care ; and
ii. whether further guidance or refresher training is needed for hospital doctors regarding use of the relevant Datix system.
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance or refresher training for hospital doctors on use of the relevant Datix system
Wider context from the report “a) I heard evidence that Mr Wells GP wrote two urgent letters to the RSFT consultant oncologist and HPB surgeon dated 22 September 2021 raising concerns that the patient had heard nothing further after the liver surgery in September 2020. These letters were sent to the East Surrey hospital by the GP. I heard evidence that both consultants hold clinics in two East Surrey hospitals as well as within their own Trust area. Principally the letters were about lack of treatment for a cancer patient and I heard evidence during the inquest that the RSFT witness assisting the court on governance & risk issues did not know the doctors had received the letters and presumably were not logged on the Datix system thereby raising concerns regarding:
i. whether additional guidance may be appropriate for GPs to know where to raise concerns about patient treatment in hospital or tertiary care; and
ii. whether further guidance or refresher training is needed for hospital doctors regarding use of the relevant Datix system .
” 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 Resolve the inter-Trust firewall problem and establish electronic data connections between the RSFT and SASH E-Tertiary systems.
Verbatim wording from the response “The firewall problem has been resolved between the two Trusts and electronic data connections can be seen between the RSFT and SASH E-Tertiary systems. This data transfer is due to be further tested by the IT and Cancer teams in the week commencing the 7th November. The system will then be tested clinically as part of a planned move of Upper Gastrointestinal Oncology patients currently managed by SASH to the care of RSFT later in November when each patient will require a transfer of information.” Source location Response from Royal Surrey Foundation Trust NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Test the E-Tertiary data transfer technically and clinically during the planned oncology patient transfer.
Verbatim wording from the response “The firewall problem has been resolved between the two Trusts and electronic data connections can be seen between the RSFT and SASH E-Tertiary systems. This data transfer is due to be further tested by the IT and Cancer teams in the week commencing the 7th November. The system will then be tested clinically as part of a planned move of Upper Gastrointestinal Oncology patients currently managed by SASH to the care of RSFT later in November when each patient will require a transfer of information.” Source location Response from Royal Surrey Foundation Trust NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete review and renegotiation of the inter-Trust SLA, incorporating learning from the inquest, and obtain final organisational sign-off.
Verbatim wording from the response “Both Trusts recognise that greater progress should have been made in reviewing and renegotiating the SLA prior to the Inquest, particularly given that the Trusts were aware of the difficulties in this case in September 2021. We would like to thank you for bringing these issues to our attention both before and during the inquest. Since the inquest the Trusts have been working to ensure that the SLA has been reviewed and renegotiated and that the learning from” Source location Response from Royal Surrey Foundation Trust NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an inter-organisation transfer pathway that gives patients, GPs and receiving clinicians the receiving organisation’s nominated contact details.
Verbatim wording from the response “Following the concerns identified during the inquest the Trusts have been working on an agreed pathway that will ensure that patients themselves receive a letter at the point when their care is due to be transferred to another organisation. This letter will contain the key contact details including a telephone number for the nominated point of contact at the receiving organisation. The patient will therefore always have the key contact details available to them. The letter will also be copied to the patients GP and to the receiving clinical nurse specialist at the receiving hospital. This ensures that the GP has access to the contact details of the nominated point of contact should they need to raise any concerns or otherwise make contact with the treating clinical team.” Source location Response from Royal Surrey Foundation Trust NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ratify and use a proforma transfer letter, providing it to patients at their final face-to-face visit and copying it to their GP and receiving Clinical Nurse Specialist.
Verbatim wording from the response “RSFT have developed a proforma letter to use at the point when a patient’s care is due to be transferred to another organisation. This letter is due to be ratified by the RSFT Oncology department on the 4th November and will then be used for all patients where care is being transferred from RSFT to our referring hospitals. Patients will receive this letter in person at their final face to face visit, this will avoid any issues with the letter being lost or delayed in a postal process and ensure that the patient is clear on how and who to contact should they have concerns following their transfer of care. The letter will then be copied to the patient’s GP and to the Clinical Nurse Specialist at the receiving Trust who will taking on the role of the nominated point of contact for that patient.” Source location Response from Royal Surrey Foundation Trust NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate the new nominated-contact process to RSFT GP partners through direct communications, the GP newsletter and the primary-secondary care meeting.
Verbatim wording from the response “When this process is ready to go live RSFT will communicate this to all of our GP partners through direct communication, our regular monthly GP newsletter and our regular monthly ‘working together’ meeting held between primary and secondary care clinicians. This will ensure that all of our local GPs are aware of the new process and that should they wish to raise concerns about a specific patient they can do so using the contact details provided for” Source location Response from Royal Surrey Foundation Trust NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The incident occurred at SASH, so RSFT had no Datix incident and relevant letters were held by SASH rather than RSFT.
Verbatim wording from the response “This concern was raised following evidence heard by yourself during the inquest that the RSFT witness assisting the court on governance and risk issues did not know that the doctors had received letters from Mr Wells’ GP raising concerns about the lack of ongoing follow up following his liver surgery.” Source location Response from Royal Surrey Foundation Trust NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Annual mandatory Datix training, governance discussions and appraisal processes provide sufficient awareness of incident-reporting requirements.
Verbatim wording from the response “To provide assurance about the raising of Datix incidents when a significant problem in patient care is identified, both Trusts can confirm that all consultants undertake yearly mandatory training which includes the use of the Datix system and the expectation for Datix reporting of incidents. The consultants also attend departmental and divisional governance meetings at which incidents are discussed that have been reported using the Datix system. There is therefore a high level of knowledge and awareness across the consultant body of the requirement to report incidents using the Datix system and of how to do this. The consultants, and all other staff members, are also aware of the need to report any patient identified as potentially lost to follow up immediately and to complete a Datix incident report.” Source location Response from Royal Surrey Foundation Trust NHS
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23 May 2019 Sasha Sabrina FORSTER · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 6 Risk of using prescribed Propranolol for overdose View source Failure to agree and update a common action plan for revoked s.17 leave View source Failure to collect and return patients to the ward when s.17 leave is revoked View source Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol View source Failure to finalise the formal revocation of s.17 leave View source Lack of shared awareness of powers and responsibilities when s.17 leave is revoked View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sasha Sabrina FORSTER · 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
Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.
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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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of using prescribed Propranolol for overdose
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it .
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to agree and update a common action plan for revoked s.17 leave
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked, or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances .
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to collect and return patients to the ward when s.17 leave is revoked
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked , was that they did not have the resources to allow them to do this , despite it being their legal responsibility so to do .
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked , placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, Sasha’s mother was given to believe that it would be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it.
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise the formal revocation of s.17 leave
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked, was that they did not have the resources to allow them to do this, despite it being their legal responsibility so to do.
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised , Sasha’s mother was given to believe that it would be , and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of shared awareness of powers and responsibilities when s.17 leave is revoked
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked , or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances.
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” Open source report
7 Apr 2017 Annette KRASINSKY-LLOYD · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Inadequate monitoring of patients in A&E View source Failure to provide timely senior supervision in A&E View source Delays in reversing anticoagulation and administering blood transfusions View source Failure to conduct timely appropriate clinical assessment View source Delays in obtaining test results View source Delays in undertaking appropriate diagnostic investigations in A&E View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Annette KRASINSKY-LLOYD · 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
Annette KRASINSKY-LLOYD died at Royal Surrey County Hospital on 20 April 2016 after an unwitnessed fall caused a pelvic fracture and retro-peritoneal haemorrhage, resulting in hypovolemic shock. The report identified inadequate A&E governance and delays in consultant involvement, investigations, reversal of anticoagulation and blood transfusions, as well as inadequate monitoring that contributed to poor intravenous access.
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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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate monitoring of patients in A&E
Wider context from the report “(3) At the time the on call consultant for medicine received Mrs KRASINSKY-LLOYD into his care, she had further deteriorated, including the fissuring of her cannula leading to poor intravenous access. Between the end of the crash call at 1147 hours and when Mrs KRASINSKY-LLOYD was transferred from the A&E department (around 1330 hours), the monitoring of Mrs KRASINSKY-LLOYD by the A&E department was inadequate giving rise to the complication relating to poor intravenous access.
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely senior supervision in A&E
Wider context from the report “(1) It was clear from the evidence that the governance and rapidity of treatment in A&E was inadequate. The SHO who initially provided care to Mrs KRASINSKY-LLOYD was left un-supervised for an extended period resulting in a delay of 90 minutes before the relevant A&E consultant engaged in the care of the patient and appropriate investigations undertaken to establish the nature of the deceased’s 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reversing anticoagulation and administering blood transfusions
Wider context from the report “(2) Notwithstanding (1) there were additional delays in obtaining results of tests and the conduct of an appropriate assessment of the deceased’s condition. This in turn led to delays in reversing the deceased’s anti-coagulation therapy and administering blood transfusions .
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct timely appropriate clinical assessment
Wider context from the report “(2) Notwithstanding (1) there were additional delays in obtaining results of tests and the conduct of an appropriate assessment of the deceased’s condition . This in turn led to delays in reversing the deceased’s anti-coagulation therapy and administering blood transfusions.
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining test results
Wider context from the report “(2) Notwithstanding (1) there were additional delays in obtaining results of tests and the conduct of an appropriate assessment of the deceased’s condition. This in turn led to delays in reversing the deceased’s anti-coagulation therapy and administering blood transfusions.
” 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 Surrey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in undertaking appropriate diagnostic investigations in A&E
Wider context from the report “(1) It was clear from the evidence that the governance and rapidity of treatment in A&E was inadequate. The SHO who initially provided care to Mrs KRASINSKY-LLOYD was left un-supervised for an extended period resulting in a delay of 90 minutes before the relevant A&E consultant engaged in the care of the patient and appropriate investigations undertaken to establish the nature of the deceased’s condition .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations