30 Jun 2025 Thomas Raymond Mallinson · Prevention of Future Deaths report Cumbria
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Concerns raised 6 Lack of clear responsibility for care of patients during illness View source Failure to notify NWAS when referred emergency calls remain unresolved View source Overcomplexity of the care system obscuring urgent care needs View source Insufficient overnight capacity to triage waiting calls View source Failure to alert call handlers to recent same-condition contacts View source Failure to alert control when transferred emergency cases remain unresolved 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
Thomas Raymond Mallinson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Raymond Mallinson became unwell with vomiting and diarrhoea and, after repeated contacts with health services over four days, was admitted to hospital gravely ill. He developed cardiogenic shock and acute kidney failure and died on 23 November 2024. The report raised concerns about delays and gaps in responsibility and communication across general practice, out-of-hours care, and ambulance services, and described the delay as amounting to neglect.
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 SSP Health; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for care of patients during illness
Wider context from the report “(1) To SSP Health, owners and operators of Carlisle Central Practice, 65 Warwick Road, Carlisle.
I wish to thank ████████ for his attendance and and assistance at the hearing. It was acknowledged that on 18th the advice "to call back tomorrow" should never have been given and that the telephone appointment the following day really ought to have been a face to face assessment either in surgery or at Thomas's home. I am concerned that no body or organization has taken responsibility for Thomas, an elderly man with significant co-morbidities, during his illness. Should this responsibility ultimately rest with a patients general practitioner, if not where does it rest?
” 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 SSP Health; that does not assign responsibility.
PFD Monitor interpretation Failure to notify NWAS when referred emergency calls remain unresolved
Wider context from the report “(2) To Cumbria Health (CH).
Thomas's case was sent electronically to the service, marked for 2 hour attention. I appreciate why this did not take place as it was impossible for clinicians on night duty to triage a large number of calls waiting while actually visiting and treating their caseload. I note a new "OPEL" system has since been instituted to try to escalate and get extra help as the number of calls waiting increases, but where will these extra resources come from overnight? I am also concerned that the referral from NWAS came as a result of a 999 emergency phone call but there seemed to be no way of telling NWAS that the call had not been dealt with and (presumably) passing responsibility back to them . As referred to above -where does responsibility lie?
” 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 SSP Health; that does not assign responsibility.
PFD Monitor interpretation Overcomplexity of the care system obscuring urgent care needs
Wider context from the report “(4) To ████████, Secretary of State for Health.
In my summing up after hearing the evidence in this case I explained the legal concept of neglect as a failure to provide basic care and (in this case) medical attention for someone in a dependent condition who can not provide it for himself, and I remarked that I felt Thomas "had fallen through an overcomplex system and was indeed neglected". I am aware that you are hoping to develop a 10 year plan for the NHS and therefore feel it my duty to highlight this case to you as an example of how overcomplexity has lost sight of a man's urgent care needs .
” 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 SSP Health; that does not assign responsibility.
PFD Monitor interpretation Insufficient overnight capacity to triage waiting calls
Wider context from the report “(2) To Cumbria Health (CH).
Thomas's case was sent electronically to the service, marked for 2 hour attention. I appreciate why this did not take place as it was impossible for clinicians on night duty to triage a large number of calls waiting while actually visiting and treating their caseload . I note a new "OPEL" system has since been instituted to try to escalate and get extra help as the number of calls waiting increases, but where will these extra resources come from overnight? I am also concerned that the referral from NWAS came as a result of a 999 emergency phone call but there seemed to be no way of telling NWAS that the call had not been dealt with and (presumably) passing responsibility back to them. As referred to above -where does responsibility lie?
” 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 SSP Health; that does not assign responsibility.
PFD Monitor interpretation Failure to alert call handlers to recent same-condition contacts
Wider context from the report “(3) To Northwest Ambulance Service (NWAS) as providers of both 111 and 999 responses in Cumbria.
There were multiple calls to 111 and 999 in this case. I was told that there was no alert to a call handler to indicate recent contacts for the same patient with the same condition which might highlight a need for more decisive action. I am also concerned that (as above) there is no system that alerts your control to the fact that a 999 (emergency) case you have passed to another agency has not fact been dealt with. A further concern refers specifically to the 111 service. At inquest it was questioned whether for out of hours GP services Cumbria had been better served when calls went to a local control room in Carlisle.
” 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 SSP Health; that does not assign responsibility.
PFD Monitor interpretation Failure to alert control when transferred emergency cases remain unresolved
Wider context from the report “(3) To Northwest Ambulance Service (NWAS) as providers of both 111 and 999 responses in Cumbria.
There were multiple calls to 111 and 999 in this case. I was told that there was no alert to a call handler to indicate recent contacts for the same patient with the same condition which might highlight a need for more decisive action. I am also concerned that (as above) there is no system that alerts your control to the fact that a 999 (emergency) case you have passed to another agency has not fact been dealt with . A further concern refers specifically to the 111 service. At inquest it was questioned whether for out of hours GP services Cumbria had been better served when calls went to a local control room in Carlisle.
” Open source report
4 Apr 2025 Hailey Anne Thompson · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to allocate medication enquiries to clinicians with appropriate competencies View source Lack of clear pathways and triage guidance for care navigators to refer urgent medication reactions to an appropriate doctor View source Failure to record clinical task communications on the medical records system 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
Hailey Anne Thompson · 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
Hailey Anne Thompson was found unresponsive at home on 19 December 2022 and died after unsuccessful resuscitation. Her death was attributed to sepsis and pneumonia arising from a Streptococcus A infection. The principal concerns were unclear pathways and guidance for care navigators handling reports of allergic reactions to medication, including referral to an appropriately competent clinician and recording an auditable trail.
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 SSP Health; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate medication enquiries to clinicians with appropriate competencies
Wider context from the report “2. During a call to the GP surgery, Hailey’s mother spoke with an administrative member of staff (who at the inquest was referred to as a care navigator at a call centre). The staff member referred an appointment to a pharmacist working with the practice to call her.
3. The pharmacist to whom this was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist. On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical records system or involved in the lessons learned process as they were not directly employed by the practice.
4. A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock.
5. No evidence was provided to:
a. explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice,
b. whether a list of clinician competencies and whom to refer tasks to was held
c. Care Navigator training
d. Algorithms or policies that apply to assist care navigator / call handlers at a centre which is not located within the doctor surgery.
6. These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or guidance on whom the required task should be referred to.
7. Instead, the task could be allocated using judgement (although as above, guidance to apply this was not clear) to a clinician who could not in fact assist , which occurred in this case. The jury who heard the inquest found that there was a missed opportunity to review the antibiotics, which was not causative in this case. In my opinion, there is a risk that an urgent need for appropriate clinical referral may not occur in the above circumstances.
” 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 SSP Health; that does not assign responsibility.
PFD Monitor interpretation Lack of clear pathways and triage guidance for care navigators to refer urgent medication reactions to an appropriate doctor
Wider context from the report “2. During a call to the GP surgery, Hailey’s mother spoke with an administrative member of staff (who at the inquest was referred to as a care navigator at a call centre). The staff member referred an appointment to a pharmacist working with the practice to call her.
3. The pharmacist to whom this was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist. On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical records system or involved in the lessons learned process as they were not directly employed by the practice.
4. A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock .
5. No evidence was provided to:
a. explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice ,
b. whether a list of clinician competencies and whom to refer tasks to was held
c. Care Navigator training
d. Algorithms or policies that apply to assist care navigator / call handlers at a centre which is not located within the doctor surgery .
6. These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or guidance on whom the required task should be referred to .
7. Instead, the task could be allocated using judgement (although as above, guidance to apply this was not clear) to a clinician who could not in fact assist, which occurred in this case. The jury who heard the inquest found that there was a missed opportunity to review the antibiotics, which was not causative in this case. In my opinion, there is a risk that an urgent need for appropriate clinical referral may not occur in the above circumstances .
” 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 SSP Health; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinical task communications on the medical records system
Wider context from the report “2. During a call to the GP surgery, Hailey’s mother spoke with an administrative member of staff (who at the inquest was referred to as a care navigator at a call centre). The staff member referred an appointment to a pharmacist working with the practice to call her.
3. The pharmacist to whom this was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist . On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical records system or involved in the lessons learned process as they were not directly employed by the practice.
4. A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock.
5. No evidence was provided to:
a. explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice,
b. whether a list of clinician competencies and whom to refer tasks to was held
c. Care Navigator training
d. Algorithms or policies that apply to assist care navigator / call handlers at a centre which is not located within the doctor surgery.
6. These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or guidance on whom the required task should be referred to.
7. Instead, the task could be allocated using judgement (although as above, guidance to apply this was not clear) to a clinician who could not in fact assist, which occurred in this case. The jury who heard the inquest found that there was a missed opportunity to review the antibiotics, which was not causative in this case. In my opinion, there is a risk that an urgent need for appropriate clinical referral may not occur in the above circumstances.
” Open source report
23 Aug 2024 Allan Robin Hamilton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to provide effective triage of electronic patient contacts by medically qualified staff View source Failure to track and regularly check electronic patient contacts View source Lack of a clear audit trail for electronic patient contacts 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
Allan Robin Hamilton · 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
Allan Robin Hamilton emailed his GP practice on 14 November 2023 about breathing difficulties, but the email was not responded to until 17 November. He was found unresponsive at home on 19 November and died from lobar pneumonia. The principal concerns were the absence of systems for tracking and triaging email queries and the lack of clear, robust audit and follow-up processes.
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 SSP Health; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective triage of electronic patient contacts by medically qualified staff
Wider context from the report “The inquest heard evidence that the GP practice in question is owned by SSP Health. The company owns a number of GP practices and that operate on a similar model. Like many GP practices the surgery in question had moved to a system where contact was encouraged electronically.
The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent .
The inquest heard evidence that an electronic system of patient referrals is only effective if there is a clear and robust process for checking regularly for patient contacts, a clear audit trial and effective triage by medically qualified members of the team .
In Mr Hamilton’s case effective scrutiny of his query and follow up contact from his GP on 14/11 and medical advice would probably have meant he would not have died when he did.
The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place.
” 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 SSP Health; that does not assign responsibility.
PFD Monitor interpretation Failure to track and regularly check electronic patient contacts
Wider context from the report “The inquest heard evidence that the GP practice in question is owned by SSP Health. The company owns a number of GP practices and that operate on a similar model. Like many GP practices the surgery in question had moved to a system where contact was encouraged electronically.
The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent.
The inquest heard evidence that an electronic system of patient referrals is only effective if there is a clear and robust process for checking regularly for patient contacts , a clear audit trial and effective triage by medically qualified members of the team.
In Mr Hamilton’s case effective scrutiny of his query and follow up contact from his GP on 14/11 and medical advice would probably have meant he would not have died when he did.
The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place.
” 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 SSP Health; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear audit trail for electronic patient contacts
Wider context from the report “The inquest heard evidence that the GP practice in question is owned by SSP Health. The company owns a number of GP practices and that operate on a similar model. Like many GP practices the surgery in question had moved to a system where contact was encouraged electronically.
The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent.
The inquest heard evidence that an electronic system of patient referrals is only effective if there is a clear and robust process for checking regularly for patient contacts, a clear audit trial and effective triage by medically qualified members of the team.
In Mr Hamilton’s case effective scrutiny of his query and follow up contact from his GP on 14/11 and medical advice would probably have meant he would not have died when he did.
The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place.
” 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