1 Nov 2023 Sasha Honey MISHABI · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 6 Failure to provide adequate monitoring and oversight of pressure ulcer policy implementation View source Failure to make required Datix incident reports for grade II lesions View source Failure to carry out a serious incident investigation when records indicate a relevant pre-admission incident View source Failure to carry out and adequately record required skin inspections View source Failure of governance review systems to identify policy compliance failures View source Failure to undertake required waterlow assessments View source See 3 more concerns
Responses linked to these concerns
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AI-generated summary
Sasha Honey MISHABI · 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 Honey MISHABI died at Queen Elizabeth Hospital Birmingham on 18 April 2023 after a cardiac arrest followed by overwhelming bronchopneumonia. He had severe physical and mental health conditions and skin ulcers that were later determined not to have significantly contributed to his death. The inquest identified failures at St Andrew’s Healthcare to complete required pressure-ulcer risk assessments and skin inspections, record them adequately, report lesions, and provide appropriate oversight, as well as failures in governance and serious-incident investigation.
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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 St Andrew's Healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate monitoring and oversight of pressure ulcer policy implementation
Wider context from the report “1. Awareness of and compliance with St. Andrew's Healthcare 'Pressure Ulcer Prevention and Management'
Policy
Due to his chronic physical health conditions Mr. Mishabi was at very high risk (score of 21) of pressure damage and ought to have had weekly waterlow assessments and daily skin inspections with more frequent assessment and inspection to be considered in the event of change such as the development of an ulcer. Statements were provided from ████████, Consultant Psychiatrist, and ████████, Lifford Ward Manager, on behalf of SAH in advance of the inquest. The statements included information on Mr. Mishabi's waterlow assessment and skin inspections, and provided some records. At no time was it identified that the SAH 'Pressure Ulcer Prevention and Management Policy' was not followed in Mr. Mishabi's case. At inquest it was identified that ████████ had forgotten that there was such a policy (he initially denied there was a policy/procedure for waterlow assessments and later, after the policy had been produced, said there was but he had forgotten about it). The areas of non compliance identified at inquest were as follows:
a. failure to undertake weekly waterlow assessments in accordance with paragraph 4.2 and 4.3 of the policy;
b. failure to carry out and/or adequately record daily skin inspections in accordance with paragraph 4.4 of the policy;
c. failure to carry out a waterlow assessment when Mr. Mishabi was identified as having what were believed to be pressure ulcers on the 15th March 2023 in accordance with paragraph 4.3 of the policy;
d. failure to consider increasing the frequency of skin inspections and carry out and/or adequately record any skin inspections between the identification of ulcers on the 15th March 2023 and the admission to hospital on the 17th March 2023 in accordance with paragraph 4.4 of the policy; and
e. failure to make a datix incident report when grade II lesions were identified on the 15th March 2023 in accordance with paragraph 4.7 of the policy; and
f. failure to provide adequate monitoring and oversight of the implementation of the policy in Mr. Mishabi's case in accordance with paragraph 5 of the policy . .
” 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 St Andrew's Healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to make required Datix incident reports for grade II lesions
Wider context from the report “1. Awareness of and compliance with St. Andrew's Healthcare 'Pressure Ulcer Prevention and Management'
Policy
Due to his chronic physical health conditions Mr. Mishabi was at very high risk (score of 21) of pressure damage and ought to have had weekly waterlow assessments and daily skin inspections with more frequent assessment and inspection to be considered in the event of change such as the development of an ulcer. Statements were provided from ████████, Consultant Psychiatrist, and ████████, Lifford Ward Manager, on behalf of SAH in advance of the inquest. The statements included information on Mr. Mishabi's waterlow assessment and skin inspections, and provided some records. At no time was it identified that the SAH 'Pressure Ulcer Prevention and Management Policy' was not followed in Mr. Mishabi's case. At inquest it was identified that ████████ had forgotten that there was such a policy (he initially denied there was a policy/procedure for waterlow assessments and later, after the policy had been produced, said there was but he had forgotten about it). The areas of non compliance identified at inquest were as follows:
a. failure to undertake weekly waterlow assessments in accordance with paragraph 4.2 and 4.3 of the policy;
b. failure to carry out and/or adequately record daily skin inspections in accordance with paragraph 4.4 of the policy;
c. failure to carry out a waterlow assessment when Mr. Mishabi was identified as having what were believed to be pressure ulcers on the 15th March 2023 in accordance with paragraph 4.3 of the policy;
d. failure to consider increasing the frequency of skin inspections and carry out and/or adequately record any skin inspections between the identification of ulcers on the 15th March 2023 and the admission to hospital on the 17th March 2023 in accordance with paragraph 4.4 of the policy; and
e. failure to make a datix incident report when grade II lesions were identified on the 15th March 2023 in accordance with paragraph 4.7 of the policy ; and
f. failure to provide adequate monitoring and oversight of the implementation of the policy in Mr. Mishabi's case in accordance with paragraph 5 of the policy. .
” 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 St Andrew's Healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out a serious incident investigation when records indicate a relevant pre-admission incident
Wider context from the report “2. SAH Governance, Quality Assurance and Serious Incident processors
a. SAH had not identified the issues with compliance with the policy before the inquest and could offer no explanation for how/why the failures occurred and persisted.
b. No serious incident investigation had been carried out by SAH into Mr. Mishabi's death because it was mistakenly believed that the ulcers developed during the admission to hospital between the 17th March and 2nd April 2023 . However, it was acknowledged in a statement from ████████ of the 14th September 2023 that there were records showing ulcers were present from the 15th March 2023 .
c. ████████ SAH Deputy Medical Director, gave evidence that the failures to comply with the policy ought to have been identified by review of the physical health dashboard in monthly ward governance huddles and the monthly divisional Integrated Quality and Performance meeting (IQPR). As there had been no investigation into what went wrong she could not explain why these systems did not work.
” 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 St Andrew's Healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out and adequately record required skin inspections
Wider context from the report “1. Awareness of and compliance with St. Andrew's Healthcare 'Pressure Ulcer Prevention and Management'
Policy
Due to his chronic physical health conditions Mr. Mishabi was at very high risk (score of 21) of pressure damage and ought to have had weekly waterlow assessments and daily skin inspections with more frequent assessment and inspection to be considered in the event of change such as the development of an ulcer. Statements were provided from ████████, Consultant Psychiatrist, and ████████, Lifford Ward Manager, on behalf of SAH in advance of the inquest. The statements included information on Mr. Mishabi's waterlow assessment and skin inspections, and provided some records. At no time was it identified that the SAH 'Pressure Ulcer Prevention and Management Policy' was not followed in Mr. Mishabi's case. At inquest it was identified that ████████ had forgotten that there was such a policy (he initially denied there was a policy/procedure for waterlow assessments and later, after the policy had been produced, said there was but he had forgotten about it). The areas of non compliance identified at inquest were as follows:
a. failure to undertake weekly waterlow assessments in accordance with paragraph 4.2 and 4.3 of the policy;
b. failure to carry out and/or adequately record daily skin inspections in accordance with paragraph 4.4 of the policy ;
c. failure to carry out a waterlow assessment when Mr. Mishabi was identified as having what were believed to be pressure ulcers on the 15th March 2023 in accordance with paragraph 4.3 of the policy;
d. failure to consider increasing the frequency of skin inspections and carry out and/or adequately record any skin inspections between the identification of ulcers on the 15th March 2023 and the admission to hospital on the 17th March 2023 in accordance with paragraph 4.4 of the policy ; and
e. failure to make a datix incident report when grade II lesions were identified on the 15th March 2023 in accordance with paragraph 4.7 of the policy; and
f. failure to provide adequate monitoring and oversight of the implementation of the policy in Mr. Mishabi's case in accordance with paragraph 5 of the policy. .
” 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 St Andrew's Healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure of governance review systems to identify policy compliance failures
Wider context from the report “2. SAH Governance, Quality Assurance and Serious Incident processors
a. SAH had not identified the issues with compliance with the policy before the inquest and could offer no explanation for how/why the failures occurred and persisted.
b. No serious incident investigation had been carried out by SAH into Mr. Mishabi's death because it was mistakenly believed that the ulcers developed during the admission to hospital between the 17th March and 2nd April 2023. However, it was acknowledged in a statement from ████████ of the 14th September 2023 that there were records showing ulcers were present from the 15th March 2023.
c. ████████ SAH Deputy Medical Director, gave evidence that the failures to comply with the policy ought to have been identified by review of the physical health dashboard in monthly ward governance huddles and the monthly divisional Integrated Quality and Performance meeting (IQPR). As there had been no investigation into what went wrong she could not explain why these systems did not work.
” 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 St Andrew's Healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake required waterlow assessments
Wider context from the report “1. Awareness of and compliance with St. Andrew's Healthcare 'Pressure Ulcer Prevention and Management'
Policy
Due to his chronic physical health conditions Mr. Mishabi was at very high risk (score of 21) of pressure damage and ought to have had weekly waterlow assessments and daily skin inspections with more frequent assessment and inspection to be considered in the event of change such as the development of an ulcer. Statements were provided from ████████, Consultant Psychiatrist, and ████████, Lifford Ward Manager, on behalf of SAH in advance of the inquest. The statements included information on Mr. Mishabi's waterlow assessment and skin inspections, and provided some records. At no time was it identified that the SAH 'Pressure Ulcer Prevention and Management Policy' was not followed in Mr. Mishabi's case. At inquest it was identified that ████████ had forgotten that there was such a policy (he initially denied there was a policy/procedure for waterlow assessments and later, after the policy had been produced, said there was but he had forgotten about it). The areas of non compliance identified at inquest were as follows:
a. failure to undertake weekly waterlow assessments in accordance with paragraph 4.2 and 4.3 of the policy ;
b. failure to carry out and/or adequately record daily skin inspections in accordance with paragraph 4.4 of the policy;
c. failure to carry out a waterlow assessment when Mr. Mishabi was identified as having what were believed to be pressure ulcers on the 15th March 2023 in accordance with paragraph 4.3 of the policy ;
d. failure to consider increasing the frequency of skin inspections and carry out and/or adequately record any skin inspections between the identification of ulcers on the 15th March 2023 and the admission to hospital on the 17th March 2023 in accordance with paragraph 4.4 of the policy; and
e. failure to make a datix incident report when grade II lesions were identified on the 15th March 2023 in accordance with paragraph 4.7 of the policy; and
f. failure to provide adequate monitoring and oversight of the implementation of the policy in Mr. Mishabi's case in accordance with paragraph 5 of the policy. .
” 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 Establish substantive clinical, nursing and operations leadership with Quality Matrons and accountable physical-health governance oversight.
Verbatim wording from the response “Change 3: Clearer Accountability and Responsibility for Physical Healthcare
Since Mr Mishabi’s death, a triumvirate leadership team consisting of substantive postholders in the roles of Clinical Director, an Associate Director of Nursing and a Director of Operations is now in place.” Source location Response from St Andrew's Healthcare
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 Audit a random sample of daily huddles to check consideration of Waterlow Pressure Scores and other physical-health tests.
Verbatim wording from the response “Action 1: Undertake an informal audit/dip test of the Daily Huddles
The Associate Director of Nursing will be undertaking a random sample of daily huddles to ensure that issues with the Waterlow Pressure Scores and other physical healthcare tests are being considered at the daily huddles.” Source location Response from St Andrew's Healthcare
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 Implement a defined escalation process and daily huddle monitoring of Waterlow, Skin Bundle and NEWS2 assessments.
Verbatim wording from the response “Change 4: Clear Escalation Plan and Daily Monitoring
A well-defined escalation process in place to address any health needs promptly, with ward managers holding responsibility.” Source location Response from St Andrew's Healthcare
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 Send all staff a reminder to complete regular Waterlow Pressure Scores and comply with Charity policies.
Verbatim wording from the response “Change 6: Charity-wide Communication
The Charity has already sent out a reminder to all staff about the importance of completing regular Waterlow Pressure Scores and complying with the Charity’s policies.” Source location Response from St Andrew's Healthcare
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 Although policy documentation was deficient, existing pressure-ulcer prevention measures were already in place and had no effect on the care available.
Verbatim wording from the response ““Mr Mishabi may have been prematurely discharged by colleagues at the QE on 2/04/23 as he was rapidly readmitted. Some liaison about how psych wards work and that the level of fitness required to be discharged to a psych ward being equivalent to that required to be managed in a domestic setting may be useful for QE colleagues going forwards.”” Source location Response from St Andrew's Healthcare
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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 Clinical governance structures were not inadequate; implementation refinement and support are now in place to address missed pressure-ulcer assessments.
Verbatim wording from the response “2.8. A significant change at the Birmingham hospital since Mr Mishabi’s admission is that there is now a designated senior nursing leadership team in the form of an Associate Director of Nursing as well as two Quality Matrons in place who have better oversight of the governance structures designed to pick up issues such as missed Waterlow Pressure Scores. It appears that it is not a case that the clinical governance structures are inadequate – more that the implementation needed some refinement and support, which is now in place.” Source location Response from St Andrew's Healthcare
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17 Oct 2023 Jason Mark BAYLEY · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Failure to accurately record medication adherence in shared clinical records View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jason Mark BAYLEY · 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
Jason Mark BAYLEY, who had chronic constipation while detained for treatment at St. Andrew's Healthcare, developed intestinal pseudo-obstruction and died at hospital on 28 December 2022. Concerns included repeated inaccurate recording of medication adherence in the Rio notes, which stated that all medication had been taken when doses of lactulose had been refused, creating a risk that staff might misunderstand whether medication had been taken and fail to plan appropriate care.
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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 St Andrew's Healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record medication adherence in shared clinical records
Wider context from the report “2. On most days between 4/12/22 and 25/12/22 when he was a detained patient on Speedwell Ward at St. Andrew's Healthcare, Mr Bayley refused to take at least one of his daily doses of lactulose which he was prescribed as part of a regime of laxatives for constipation. While these refusals were documented in the Electronic Prescribing and Medicines Administration document, there were four occasions when it was incorrectly documented that all medication had been taken under the 'Medication Adherence' section in the Rio notes .
3. The Rio notes are the daily working records to which all staff have access. The reporting of medication adherence is specifically prompted in the Rio notes. It is of concern that, owing to a breakdown in communication between staff, the Rio notes repeatedly stated that all medication had been taken when it had not .
4. I am concerned that accurate documentation of whether medication has been taken in the Rio notes is an important safeguard against harm and a mechanism to promote appropriate care planning. I am concerned that there may be a risk to the life of some patients if staff understand that medication has been taken when it has not.
” 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 Audit medication-related Rio notes against ePMA records to assess the extent of inaccurate documentation.
Verbatim wording from the response “4.1 In order to address the issue with the inaccuracy of the Rio notes that relate to medication the Charity is undertaking the following actions:” Source location Response from St Andrew's Healthcare
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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 Require Care Plan Update Meetings and ward rounds to review patients’ previous two weeks of ePMA medication records.
Verbatim wording from the response “Action 3: Ensuring CPUMs review EPMA data
4.4 The Charity senior clinicians have communicated to their medical colleagues that every Care Plan Update Meeting/Ward Round should include a review of the last two weeks medication records on ePMA. This will ensure missed doses of medication will be noticed even if the Rio notes are incorrect.” Source location Response from St Andrew's Healthcare
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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 Investigate whether ePMA can alert responsible clinicians when consecutive medication doses are missed, including alert-fatigue effects.
Verbatim wording from the response “4.6 In addition, the Charity is investigating if an ePMA can send a patient’s responsible clinician an alert if consecutive doses of medication are missed by a patient. In addition to the technical feasibility of this proposed development, the Charity also needs to consider the effect of ‘alert fatigue’ in the sense that the effectiveness of such alerts will be reduced if key clinicians receive too many alerts as they will start to be ignored.” Source location Response from St Andrew's Healthcare
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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 Assess whether ePMA can automatically create Rio progress notes documenting medication administration events.
Verbatim wording from the response “Action 4: Investigating a technical solution
4.5 The Charity is currently undertaking a project to consider if ePMA can automatically make a Rio progress note documenting medication administration events. This would negate the need for this information to be included in the shift summary notes.” Source location Response from St Andrew's Healthcare
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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 Speak with colleagues who made inaccurate entries and remind them during management supervision about accurate record keeping.
Verbatim wording from the response “3.1 Having compared the missed doses of lactulose with the inaccurate Rio notes we have noted that on every occasion the Rio note was made by a colleague who was different to the one who administered the medication. During this period, where Mr Bayley missed a dose of lactulose and the Rio note documenting the shift handover was made by the person who administered his medication the Rio note is accurate. The staff making these notes vary in seniority from healthcare assistants to a deputy ward manager.” Source location Response from St Andrew's Healthcare
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 Disseminate messages to all colleagues on accurate record keeping and documenting missed medication doses in Rio.
Verbatim wording from the response “Action 2: Reminding staff of the importance of good record keeping
4.3 The Charity has a weekly clinical briefing called the Pulse which is received by all colleagues. We have included a message on the importance of accurate record keeping as well as another on the importance of documenting in Rio if a patient misses a dose of medication.” Source location Response from St Andrew's Healthcare
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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 Existing ePMA records, regular care reviews and the Patient Safety Dashboard adequately address risks from inaccurate medication information in Rio notes.
Verbatim wording from the response “5.3 We would also highlight that you may not have been provided with detailed information of how the Charity’s EPR systems operate and are reviewed, which would have given you a better understanding of how the ePMA is used by clinicians. The Charity’s position is that the prominent system for checking the prescribing and administration of medication is ePMA which is regularly checked by doctors and is used by nurses at every instance of medication administration. There are therefore controls in place which address the risk of incorrect information about medication administration being entered into the progress notes of Rio, which is not the main system for medication management.” Source location Response from St Andrew's Healthcare
Open published response
29 Sep 2023 Steven Sanders · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Failure to adequately mitigate illicit substance use, entry and distribution within SAH View source Presence and supply of highly potent synthetic opioids View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Steven Sanders · 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
Steven Sanders was a detained patient at St Andrew's Healthcare who was found unresponsive and not breathing on 20 November 2022 after returning from authorised leave, and was pronounced deceased at 23:04. A pathologist initially attributed his death to coronary artery disease, but later information raised suspicion that he may have taken an illicit substance. The principal concern was that illicit substances were entering and being distributed within the hospital, creating a risk to life among vulnerable detained patients.
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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 St Andrew's Healthcare; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately mitigate illicit substance use, entry and distribution within SAH
Wider context from the report “Initially there was no evidence that illegal drugs were more widely being used and supplied within SAH and the hospital provided evidence of its policies and procedures for searches to address this risk and asserted that these policies and procedures were in appropriate operation.
However, on the 24th July 2023 I was informed that during a routine room search of Hurst ward (another secure ward in SAH Birmingham) over the weekend of the 22nd/23rd July 2023 a quantity of drugs and a lighter were discovered in a patient’s room. The patient (Patient A) whose room these items were found in alleged that these drugs were given to him by Mr Steven Sanders when they were both patients on Hawksley ward. SAH has confirmed that the patient and Mr Sanders were cared for on Hawksley ward at the same time prior to Mr Sanders’ death. The following further information was then provided by SAH on the 27th July 2023: the room search occurred on 23rd July, ████████ found in Patient A’s room, Patient A disclosed the substance ████████ from Mr Sanders on the day he died (20th November 2022) after Mr Sanders returned from unescorted leave, Patient A got ████████ from another patient, Patient B, whilst on Hawksley Ward. Patient A also disclosed that Patient B had brought ████████ into Hawksley Ward.
Subsequently, on the 24th July 2023 Patient A was found with what appeared to be cocaine in his room and he had hidden it in his anus during the room search on the 23rd July.
I wrote to the CQC and WMP on the 28th July 2023 explaining my concerns. I have not yet received any update on the action taken to date by the CQC. It was agreed at a meeting with WMP on the 11th August 2023 that they would conduct some enquiries, but I have not had any update on those enquiries.
Today I have become aware that on the 24th September 2023 a report was made to West Midlands Police that a patient had been supplying drugs to other patients. The details were that he had been keeping ████████. Three patients had tested positive for ████████ and a further 5 patients were acting under influence.
Also, on the 24th September 2023 another detained patient (Patient C) was found deceased lying on his bed in unexplained and unexpected circumstances. A separate investigation is being undertaken into Patient C’s death and it remains to be ascertained whether his death was drug related.
I am deeply concerned that the risk of illicit substance use is not being adequately mitigated at SAH and there is an endemic problem. This risk creates an obvious risk to life not merely from the risk of death inherent in illicit substance use but also because the population of SAH is particularly vulnerable: many suffer from mental illness affecting their judgement and assessment of risk, there will be a history of drug use amongst many patients and those patients taking illicit substances may not have an accurate perception of their tolerance due to their time in detention. The risk of death is also increased by the current presence of ████████ (new and highly potent synthetic opioids) ████████ being supplied within the West Midlands.
There needs to be an urgent and thorough investigation into all these incidents to identify how drugs are entering and being distributed within SAH and how this risk can be mitigated as far as possible in the future.
” 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 St Andrew's Healthcare; that does not assign responsibility.
PFD Monitor interpretation Presence and supply of highly potent synthetic opioids
Wider context from the report “Initially there was no evidence that illegal drugs were more widely being used and supplied within SAH and the hospital provided evidence of its policies and procedures for searches to address this risk and asserted that these policies and procedures were in appropriate operation.
However, on the 24th July 2023 I was informed that during a routine room search of Hurst ward (another secure ward in SAH Birmingham) over the weekend of the 22nd/23rd July 2023 a quantity of drugs and a lighter were discovered in a patient’s room. The patient (Patient A) whose room these items were found in alleged that these drugs were given to him by Mr Steven Sanders when they were both patients on Hawksley ward. SAH has confirmed that the patient and Mr Sanders were cared for on Hawksley ward at the same time prior to Mr Sanders’ death. The following further information was then provided by SAH on the 27th July 2023: the room search occurred on 23rd July, ████████ found in Patient A’s room, Patient A disclosed the substance ████████ from Mr Sanders on the day he died (20th November 2022) after Mr Sanders returned from unescorted leave, Patient A got ████████ from another patient, Patient B, whilst on Hawksley Ward. Patient A also disclosed that Patient B had brought ████████ into Hawksley Ward.
Subsequently, on the 24th July 2023 Patient A was found with what appeared to be cocaine in his room and he had hidden it in his anus during the room search on the 23rd July.
I wrote to the CQC and WMP on the 28th July 2023 explaining my concerns. I have not yet received any update on the action taken to date by the CQC. It was agreed at a meeting with WMP on the 11th August 2023 that they would conduct some enquiries, but I have not had any update on those enquiries.
Today I have become aware that on the 24th September 2023 a report was made to West Midlands Police that a patient had been supplying drugs to other patients. The details were that he had been keeping ████████. Three patients had tested positive for ████████ and a further 5 patients were acting under influence.
Also, on the 24th September 2023 another detained patient (Patient C) was found deceased lying on his bed in unexplained and unexpected circumstances. A separate investigation is being undertaken into Patient C’s death and it remains to be ascertained whether his death was drug related.
I am deeply concerned that the risk of illicit substance use is not being adequately mitigated at SAH and there is an endemic problem. This risk creates an obvious risk to life not merely from the risk of death inherent in illicit substance use but also because the population of SAH is particularly vulnerable: many suffer from mental illness affecting their judgement and assessment of risk, there will be a history of drug use amongst many patients and those patients taking illicit substances may not have an accurate perception of their tolerance due to their time in detention. The risk of death is also increased by the current presence of ████████ (new and highly potent synthetic opioids) ████████ being supplied within the West Midlands.
There needs to be an urgent and thorough investigation into all these incidents to identify how drugs are entering and being distributed within SAH and how this risk can be mitigated as far as possible in the future.
” Open source report
16 Sep 2019 Blaithin Grianne Buckley · Prevention of Future Deaths report Northamptonshire
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Concerns raised 2 Lack of guidance on whether and when to call an ambulance during mobilisation of the medical emergency team View source Delays in calling an ambulance for transfer in a medical emergency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Blaithin Grianne Buckley · 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
Blaithin Grianne Buckley died at Northampton General Hospital on 30 April 2018 after being found hanging in a phone booth at St. Andrews Healthcare while on five-minute observations. Concerns included the delay in calling an ambulance and uncertainty about whether procedures adequately explained when an ambulance should be called. The inquest also identified failures relating to locking the phone booth, transferring relevant patient history, and the process for calling the ambulance service.
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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 St Andrew's Healthcare; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on whether and when to call an ambulance during mobilisation of the medical emergency team
Wider context from the report “(1) The delay in calling for an ambulance to transfer Ms Buckley to the General Hospital in a clear medical emergency.
There was no evidence before inquest to explain the delay between 23:20 and 23:44. Whilst it had been accepted that senior clinicians, with greater medical knowledge that the paramedics, formed the medical emergency team, St Andrews as a mental health setting was required to transfer Ms Buckley to A&E in any event.
It was unclear whether the policies/procedures requiring the mobilisation of the medical emergency team included guidance on whether an ambulance should be called, and when.
” 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 St Andrew's Healthcare; that does not assign responsibility.
PFD Monitor interpretation Delays in calling an ambulance for transfer in a medical emergency
Wider context from the report “(1) The delay in calling for an ambulance to transfer Ms Buckley to the General Hospital in a clear medical emergency.
There was no evidence before inquest to explain the delay between 23:20 and 23:44. Whilst it had been accepted that senior clinicians, with greater medical knowledge that the paramedics, formed the medical emergency team, St Andrews as a mental health setting was required to transfer Ms Buckley to A&E in any event.
It was unclear whether the policies/procedures requiring the mobilisation of the medical emergency team included guidance on whether an ambulance should be called, and when.
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PFD Monitor interpretation Automatically call an ambulance whenever a medical emergency is called, rather than leaving the decision to the nursing team.
Verbatim wording from the response “4) One specific and significant change in the procedure that has already been implemented is that when a medical emergency is called, an ambulance is also called rather than leaving it to the discretion of the nursing team as was previously the case. This will enable a faster response to medical emergencies. Action completed on 7 November 2019.” Source location 2019-0465-Response-from-St-Andrews-Healthcare-R-pdf
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor medical emergencies and ambulance attendances through the physical healthcare governance meeting, escalating identified problems or challenges.
Verbatim wording from the response “5) Responses to medical emergencies including ambulance attendances will be monitored in the relevant governance meeting chaired by the Director of Physical Healthcare (the medical physical healthcare group) with necessary escalation where problems or challenges are found.” Source location 2019-0465-Response-from-St-Andrews-Healthcare-R-pdf
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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 Review and refresh the deteriorating-patient policy to clarify actions when physical health deteriorates and medical intervention is required.
Verbatim wording from the response “3) The policy concerning the management of a deteriorating patient is being reviewed and refreshed to provide clarity on the actions to be taken in the event of a patient experiencing deteriorating physical health and requiring medical intervention. This is due for implementation on or before 1 January 2020.” Source location 2019-0465-Response-from-St-Andrews-Healthcare-R-pdf
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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 Earlier arrival at the General Hospital would not have altered the outcome in this case.
Verbatim wording from the response “Further to the Regulation 28 notice received by St Andrew’s Healthcare dated 15 September 2018, I am providing a response to the matter of concern which was the delay in calling for an ambulance to transfer Ms Buckley to the General Hospital. While the evidence provided to the Court indicated that an earlier arrival at the General Hospital would not have altered the outcome in this instance, St Andrew’s recognises that there is a need for greater clarity around the recognition of a medical emergency and how and when an ambulance is called. To that end the Charity has taken the following steps:” Source location 2019-0465-Response-from-St-Andrews-Healthcare-R-pdf
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations