9 May 2022 Raymond Griffiths · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 11 Restrictions on cardiac surgery training View source Restrictions in cardiac surgical capacity causing diversion to overstretched units View source Damage to public confidence in the cardiac surgery department, SGH and the NHS View source Collapse of cardiac surgery research View source Failure of the SJR process to identify lessons for patient safety improvement View source Restrictions on cardiac surgeons' operating rights reducing cardiac surgical capacity View source Damage to public confidence discouraging patients from presenting for care View source SJR process undermining staff morale, mental health and confidence View source Risk-averse surgical decision-making denying care to complex patients View source Loss of cardiac surgery staff View source SJR process failing to provide an appropriate audit of NHS work View source See 8 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
Raymond Griffiths · 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
Raymond Griffiths was admitted to St George’s Hospital for coronary artery bypass grafting on 21 May 2013, underwent surgery the following day, developed acute on chronic liver failure post-operatively, and died in intensive care three days later. The inquest concluded that his care was beyond reproach and that his liver failure could not reasonably have been predicted or prevented. The report raised concerns about restrictions on cardiac surgical capacity, diversion of emergency and other patients, damage to public confidence, and the adequacy of the SJR process, which were considered capable of increasing risks to future patients.
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 St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Restrictions on cardiac surgery training
Wider context from the report “8. That restrictions on training , collapse of research and staff leaving, further damages not only the cardiac surgery at SGH but also the wider cardiac surgery field, increasing the risk of death to patients by reducing their access to high quality care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Restrictions in cardiac surgical capacity causing diversion to overstretched units
Wider context from the report “1. That restrictions in cardiac surgical capacity at SGH is causing patients to be diverted to other overstretched units, increasing their risk of death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Damage to public confidence in the cardiac surgery department, SGH and the NHS
Wider context from the report “7. That the apparently unfounded damage to the reputation of the cardiac surgery department will take years to repair, increasing the risks of future deaths by damaging public confidence in SGH and the NHS .
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Collapse of cardiac surgery research
Wider context from the report “8. That restrictions on training, collapse of research and staff leaving, further damages not only the cardiac surgery at SGH but also the wider cardiac surgery field, increasing the risk of death to patients by reducing their access to high quality care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of the SJR process to identify lessons for patient safety improvement
Wider context from the report “4. That the evidentially inadequate and critical SJR process has failed to identify factors from which lessons could have been learnt and thus patient safety improved, and future deaths prevented.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Restrictions on cardiac surgeons' operating rights reducing cardiac surgical capacity
Wider context from the report “6. That the apparently unnecessary restrictions on operating rights of the cardiac surgeons is reducing the overall capacity for cardiac surgery and thus may increase the risk of death for patients awaiting such surgery, as they die on waiting lists.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Damage to public confidence discouraging patients from presenting for care
Wider context from the report “3. That public confidence has been so dented that patients requiring care have been discouraged from presenting to SGH thus increasing their risk of death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation SJR process undermining staff morale, mental health and confidence
Wider context from the report “5. That this SJR process has undermined the department unnecessarily , impacting on morale and the mental health and confidence of the cardiac surgeons and other clinicians and non-clinicians within SGH which may translate into a lower quality of care for patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Risk-averse surgical decision-making denying care to complex patients
Wider context from the report “9. The restrictions at SGH may make surgeons more risk adverse and thus deny care to the most complex patients and so increase the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Loss of cardiac surgery staff
Wider context from the report “8. That restrictions on training, collapse of research and staff leaving , further damages not only the cardiac surgery at SGH but also the wider cardiac surgery field, increasing the risk of death to patients by reducing their access to high quality care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation SJR process failing to provide an appropriate audit of NHS work
Wider context from the report “10. That the SJR process as deployed in SGH is not fit for purpose , further undermining the public confidence in the NHS, which the public may perceive as the NHS being unable to appropriately audit its own work .
” Open source report
21 Apr 2021 Susan Janet ADAMS · Prevention of Future Deaths report Staffordshire South
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Concerns raised 1 Failure of cross-county commissioning arrangements to ensure coordinated secondary psychiatric care 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
Susan Janet ADAMS · 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
Susan Adams was found dead in a hotel in Sutton Coldfield on 4 November 2020 after being unable to live at her home in Tamworth. Her death resulted from the consequences of excessive alcohol consumption, with the inquest recording combined toxicity of ethanol, pregabalin and fentanyl with hepatic cirrhosis and steatosis. The report raised concerns about commissioning difficulties affecting access to regular secondary psychiatric care because her home address and GP practice were in different counties.
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 St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of cross-county commissioning arrangements to ensure coordinated secondary psychiatric care
Wider context from the report “Mrs Adams and her family lived in Dosthill, Tamworth, Staffordshire. I was told that this was approximately 50 feet from the border with Warwickshire (and not far from West Midlands as well) and that her GP Practice was in Kingsbury Warwickshire. She needed regular psychiatric assistance from secondary mental health services and I was advised there were significant commissioning difficulties with this because of the home address and GP Practice being in different counties . Mrs Adams could access the crisis team in Staffordshire but long term treatment was supposedly to be provided in Warwickshire . This may have impacted on the care that Mrs Adams received and could be relevant for others who live close to county boundaries. I wonder if anything can be done to facilitate arrangements for secondary psychiatric care in these circumstances.
” Open source report
16 May 2019 Daniel Davey · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 5 Failure of prison and healthcare staff to jointly manage in-possession medication risks and intervene promptly View source Failure to ensure healthcare attendance or input at ACCT reviews View source Inadequate advance notification and information sharing for ACCT reviews View source Failure to review in-possession medication risk assessments when risk changes View source Inadequate cell searching and collection of in-possession medication after a change of risk View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Daniel Davey · 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
Daniel Davey, aged 21, died at John Radcliffe Hospital on 12 January 2018 after deliberately overdosing on propranolol in his cell at HMP Bullingdon Prison. The report raises concerns about healthcare attendance at ACCT reviews, risk assessments and management of in-possession medication, cell searches, and failures to share and act on information relevant to his safety.
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 St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of prison and healthcare staff to jointly manage in-possession medication risks and intervene promptly
Wider context from the report “2. Reviews of ‘in possession’ medication risk assessments – The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. I heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. I was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy.
In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself. I understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed. I appreciate a review might not necessarily result in medication being taken away. I also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away.
A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication . It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment . It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary .
This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened. I did not hear much evidence about practice or policies relating to searching and potentially removing medication. This is clearly a task that rests with prison staff and it would be helpful to have further information about this.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure healthcare attendance or input at ACCT reviews
Wider context from the report “1. Healthcare attendance at ACCT reviews – This concern relates to both the prison and healthcare. It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews . This is a significant concern and it is not in accordance with local and national policy. I understand that there were occasions when prison staff requested healthcare attendance, but no one was available . The system of providing advance notification to healthcare about the date of ACCT reviews was not comprehensive. It resulted in ACCT reviews, as in this case, taking place without information being available to the assessor/reviewer. For example, information about suicidal ideation/attempts and other information disclosed to healthcare and also information about ‘in possession medication’. Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone). It would be helpful if there could be a further level of reassurance provided, firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly, a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate advance notification and information sharing for ACCT reviews
Wider context from the report “1. Healthcare attendance at ACCT reviews – This concern relates to both the prison and healthcare. It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews. This is a significant concern and it is not in accordance with local and national policy. I understand that there were occasions when prison staff requested healthcare attendance, but no one was available. The system of providing advance notification to healthcare about the date of ACCT reviews was not comprehensive . It resulted in ACCT reviews, as in this case, taking place without information being available to the assessor/reviewer . For example, information about suicidal ideation/attempts and other information disclosed to healthcare and also information about ‘in possession medication’. Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone). It would be helpful if there could be a further level of reassurance provided, firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly, a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to review in-possession medication risk assessments when risk changes
Wider context from the report “2. Reviews of ‘in possession’ medication risk assessments – The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. I heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. I was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy.
In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself . I understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed . I appreciate a review might not necessarily result in medication being taken away. I also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away.
A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication. It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment. It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary.
This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened. I did not hear much evidence about practice or policies relating to searching and potentially removing medication. This is clearly a task that rests with prison staff and it would be helpful to have further information about this.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate cell searching and collection of in-possession medication after a change of risk
Wider context from the report “2. Reviews of ‘in possession’ medication risk assessments – The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. I heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. I was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy.
In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself. I understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed. I appreciate a review might not necessarily result in medication being taken away. I also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away.
A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication. It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment. It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary.
This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened . I did not hear much evidence about practice or policies relating to searching and potentially removing medication . This is clearly a task that rests with prison staff and it would be helpful to have further information about this.
” Open source report
7 Mar 2018 Ms Ivanika Olivari · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 8 Failure to prioritise risk to life in urgent and emergency situations View source Failure to update relevant staff training promptly and audibly View source Department of Health guidance failing to clearly permit leaving messages for patients in urgent and emergency situations View source Failure to attempt patient contact through all available contact phone numbers in urgent and emergency situations View source GMC guidance failing to clearly permit leaving messages for patients in urgent and emergency situations View source Failure to communicate urgent and emergency guidance clarifications to doctors and relevant NHS staff View source Failure to leave answerphone messages enabling patient contact in urgent and emergency situations View source Hospital guidelines failing to reflect required urgent and emergency communication and life-risk priorities View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ms Ivanika Olivari · 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
Ms Ivanika Olivari died on 3 August 2017 at St George’s Hospital after suffering a cardiac arrest at home associated with a malfunctioning pacemaker. The principal concerns were failures to leave a message or use all available contact numbers in an urgent situation, and the need for guidance, policies and staff training to prioritise risk to life and permit appropriate messages to patients.
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 St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise risk to life in urgent and emergency situations
Wider context from the report “3. That in urgent and emergency situations risk to life should be considered the priority .
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to update relevant staff training promptly and audibly
Wider context from the report “5. That hospitals and St George's Hospital in particular, should ensure that all relevant staff have their training updated in a prompt and auditable fashion to reflect the concerns raised above.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Department of Health guidance failing to clearly permit leaving messages for patients in urgent and emergency situations
Wider context from the report “7. That the Department of Health also considers its guidance that it issues in relation to such matters, and amend where necessary to ensure that it is clear that messages may be left for patients in urgent and emergency situations .
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to attempt patient contact through all available contact phone numbers in urgent and emergency situations
Wider context from the report “2. That doctors should attempt to contact patients via all contact phone numbers that they have access to for patients in urgent and emergency situations.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation GMC guidance failing to clearly permit leaving messages for patients in urgent and emergency situations
Wider context from the report “6. That the GMC considers its guidance for doctors and amend where necessary to ensure that it is clear that messages may be left for patients in urgent and emergency situations .
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate urgent and emergency guidance clarifications to doctors and relevant NHS staff
Wider context from the report “8. That the GMC and Department of Health both take steps to ensure that the clarifications as outlined above are communicated to all doctors by the GMC and to all relevant staff employed by the NHS by the Department of Health .
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to leave answerphone messages enabling patient contact in urgent and emergency situations
Wider context from the report “1. That doctors should leave messages on answerphones for patients to make contact with them in urgent and emergency situations .
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Hospital guidelines failing to reflect required urgent and emergency communication and life-risk priorities
Wider context from the report “4. That hospital guidelines and St George’s hospital guidelines in particular , in relation to such matters, should be updated and amended to reflect the above where needed .
” Open source report
20 Nov 2017 Robert John Richards · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 15 Inadequate staff training for managing bullying View source Inadequate communication between healthcare, psychological, psychiatric and prison staff View source Inadequate medical staff training in resuscitation View source Failure of the system for restocking used medical supplies View source Inappropriate mixing of vulnerable prisoners with non-vulnerable prisoners in the vulnerable prisoners’ unit View source Inadequate systems for managing bullying View source Poor recognition of bullying risk View source Inadequate security and intelligence systems for identifying and containing bullying and crime risks View source Insufficient staffing for managing bullying View source Regular passage of prisoners from other wings through the vulnerable prisoners’ unit View source Poor communication between teams about bullying risks View source Absence of a personal officer system providing prisoners with a named officer who knows them well View source Failure to undertake risk assessments of prisoners before sentencing View source Inappropriate cell allocation for vulnerable prisoners View source Mixing of vulnerable prisoners with potential bullies View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Robert John Richards · 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
Robert John Richards died by suicide after being found hanging by a sheet in his cell at HMP Wandsworth on 29 July 2014. The report identified concerns about bullying, extortion, inadequate risk management and communication, unsuitable cell allocation, staffing and training, and failings in resuscitation equipment and procedures.
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 St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training for managing bullying
Wider context from the report “1. That bullying within HMP Wandsworth is not appropriately managed due to inadequate systems being in place, too few staff on duty, poor communication between teams, inadequate staff training , poor recognition of risk and the mixing of vulnerable prisoners with potential bullies.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between healthcare, psychological, psychiatric and prison staff
Wider context from the report “7. That the communications interface between the medical staff, those supplying psychological support and psychiatric services needs to be improved , as does the communication of these staff with prison officers , such that risks of self harm and bullying are appropriately communicated and acted upon.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate medical staff training in resuscitation
Wider context from the report “5. That training of medical staff in relation to Resuscitation is inadequate .
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of the system for restocking used medical supplies
Wider context from the report “6. That the system for ensuring restocking of medical supplies such as oxygen after they have been used needs to be reviewed.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Inappropriate mixing of vulnerable prisoners with non-vulnerable prisoners in the vulnerable prisoners’ unit
Wider context from the report “2. The organisation of the vulnerable prisoners’ unit is such that those truly vulnerable are mixed with those prisoners placed there for reasons as drug debt from other wings, who are not vulnerable in other ways and then abuse prisoners such as Mr Richards.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate systems for managing bullying
Wider context from the report “1. That bullying within HMP Wandsworth is not appropriately managed due to inadequate systems being in place , too few staff on duty, poor communication between teams, inadequate staff training, poor recognition of risk and the mixing of vulnerable prisoners with potential bullies.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Poor recognition of bullying risk
Wider context from the report “1. That bullying within HMP Wandsworth is not appropriately managed due to inadequate systems being in place, too few staff on duty, poor communication between teams, inadequate staff training, poor recognition of risk and the mixing of vulnerable prisoners with potential bullies.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate security and intelligence systems for identifying and containing bullying and crime risks
Wider context from the report “9. That security and intelligence systems are upgraded and overhauled such that risks of bullying and crime within the prison that feed into self-harm and suicide by prisoners are reduced and contained appropriately.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing for managing bullying
Wider context from the report “1. That bullying within HMP Wandsworth is not appropriately managed due to inadequate systems being in place, too few staff on duty , poor communication between teams, inadequate staff training, poor recognition of risk and the mixing of vulnerable prisoners with potential bullies.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Regular passage of prisoners from other wings through the vulnerable prisoners’ unit
Wider context from the report “3. That prisoners from other wings pass through the VP unit on a regular basis and thus increase the chance of bullying to the vulnerable prisoners.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Poor communication between teams about bullying risks
Wider context from the report “1. That bullying within HMP Wandsworth is not appropriately managed due to inadequate systems being in place, too few staff on duty, poor communication between teams , inadequate staff training, poor recognition of risk and the mixing of vulnerable prisoners with potential bullies.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Absence of a personal officer system providing prisoners with a named officer who knows them well
Wider context from the report “10. That the personal officer system be re-established , so that prisoners have a named officer who knows them well . Risks should then be communicated and managed more appropriately within HMP Wandsworth, such that self-harm and suicide of prisoners is reduced.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake risk assessments of prisoners before sentencing
Wider context from the report “8. That there is a risk assessment undertaken of prisoners in the approach to sentencing so that any increase in risk may be appropriately managed.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Inappropriate cell allocation for vulnerable prisoners
Wider context from the report “4. That the system for cell allocation is inappropriate such that a young and immature and vulnerable man such as Mr Richards was sharing a cell with a prisoner with convictions for predatory sexual behaviour with boys.
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Mixing of vulnerable prisoners with potential bullies
Wider context from the report “1. That bullying within HMP Wandsworth is not appropriately managed due to inadequate systems being in place, too few staff on duty, poor communication between teams, inadequate staff training, poor recognition of risk and the mixing of vulnerable prisoners with potential bullies .
” Open source report
8 Dec 2016 Mary Patricia MULDOWNEY · Prevention of Future Deaths report Inner North London
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Concerns raised 1 Unavailability of intensive care beds for time-critical specialist neurosurgical transfers 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
Mary Patricia MULDOWNEY · 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
Mary Patricia Muldowney suffered a spontaneous subarachnoid haemorrhage caused by a ruptured artery and was admitted to East Surrey Hospital on 20 July 2016. Several hospitals refused urgent transfer to specialist neurosurgical care because intensive care beds were unavailable; she was eventually transferred and underwent surgery, but died after her condition deteriorated during transfer. The principal concern was that the lack of an immediately available intensive care bed delayed time-critical surgery, which the report states she probably would have survived if performed promptly.
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 St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of intensive care beds for time-critical specialist neurosurgical transfers
Wider context from the report “In the light of the gravity of Ms Muldowney’s situation, with the only definitive treatment being surgery, she required immediate transfer to a specialist neurosurgical unit, yet she was refused transfer by at least three hospitals who said they had no intensive care beds.
She could have been transferred, undergone surgery, spent time in recovery, and then an intensive care bed procured, perhaps even by transferring out a non neurosurgical patient.
If such a bed was still unavailable, she could then have been transferred to a different hospital , at least having undergone the time critical clot evacuation and aneurysm clipping.
With prompt transfer and surgery, Ms Muldowney would probably have survived.
” Open source report
21 Jan 2016 Leslie Douglas Murray · Prevention of Future Deaths report Inner West London
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Concerns raised 1 Insufficient cover for required 1:1 patient care 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
Leslie Douglas Murray · 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
Leslie Douglas Murray, who required 1:1 nursing care, fell from his hospital bed when adequate cover was unavailable and sustained injuries that led to his death the following day. The principal concern was insufficient staffing to provide 1:1 care, resulting in preventable falls or other care deficiencies that could cause or contribute to death.
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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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient cover for required 1:1 patient care
Wider context from the report “(1) That insufficient cover is provided to allow 1:1 care to be given to patients that require it on this ward (Holdsworth) and likely others throughout the hospital, and as such patients are suffering preventable falls that may be causing fatal injury, or suffering other care deficiencies that may cause or contribute to death.
” Open source report
24 Dec 2015 Angela Catherine Brealey · Prevention of Future Deaths report Staffordshire South
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Concerns raised 4 Serious incident reviews failing to identify treatment concerns View source Failure to protect confidentiality of information provided by third parties View source Insufficient involvement of a multi-disciplinary team in care View source Lack of a defined process for acknowledging and recording information received from third parties View source See 1 more concern
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
Angela Catherine Brealey · 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
Angela Brealey was found dead at home on 19 September 2014 after hanging herself. She was receiving treatment from local secondary psychiatric services, but no full assessment by a Consultant Psychiatrist had been carried out. Concerns included the handling and confidentiality of information from third parties, limited multidisciplinary team involvement, and whether pressure on serious incident reviewers reduced the effectiveness of the review.
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 St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Serious incident reviews failing to identify treatment concerns
Wider context from the report “(3) Generally the serious incident review process is a very helpful one. In this particular case however a number of concerns about Angela’s treatment were not picked up by the review. Is pressure on those carrying out this process reducing the effectiveness of the reports?
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to protect confidentiality of information provided by third parties
Wider context from the report “(1) At the Inquest I heard various evidence about what should happen to information received from third parties concerning a person receiving treatment from the Trust. This does feature in the action plan prepared following the Inquest but I think the process should be looked at on quite a wide basis. Should information received from a third party be acknowledged at all? If so, how? How much of lengthy communications received from third parties should be recorded? Is entry on the RIO medical notes sufficient in itself? How is patient confidentiality protected in these circumstances and what about circumstances where third parties request confidentiality for information they have provided?
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient involvement of a multi-disciplinary team in care
Wider context from the report “(2) During the period that Angela was receiving assistance from the Trust there is minimal evidence of a multi-disciplinary team being involved.
Predominantly one community mental health nurse took responsibility. While it may not have affected the outcome in this case a team approach involving a number of professionals may have been preferable. Is this something that the Trust needs to look at?
” 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 George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a defined process for acknowledging and recording information received from third parties
Wider context from the report “(1) At the Inquest I heard various evidence about what should happen to information received from third parties concerning a person receiving treatment from the Trust. This does feature in the action plan prepared following the Inquest but I think the process should be looked at on quite a wide basis. Should information received from a third party be acknowledged at all? If so, how? How much of lengthy communications received from third parties should be recorded? Is entry on the RIO medical notes sufficient in itself? How is patient confidentiality protected in these circumstances and what about circumstances where third parties request confidentiality for information they have provided?
” Open source report
5 Mar 2014 Mr John Patrick Fox · Prevention of Future Deaths report Inner West London
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Concerns raised 1 Reduced physiotherapy services on bank holidays and weekends 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
Mr John Patrick Fox · 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
Mr John Patrick Fox, aged 93, sustained a fractured neck of femur in an accidental fall at home and died on 1 January 2014 after treatment for the fracture and underlying heart problems. The report raised concern that reduced physiotherapy services on bank holidays and weekends could increase the risk of post-operative complications in vulnerable patients.
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 St George's Hospital; that does not assign responsibility.
PFD Monitor interpretation Reduced physiotherapy services on bank holidays and weekends
Wider context from the report “That there is a reduced level of physiotherapy services on bank holidays and weekends , increasing the risk of post operative complications developing in vulnerable patients.
” 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