Recipient

St James's University Hospital

First report 1 Mar 2016•Latest report 3 Mar 2016

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from St James's University Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

3 Mar2016
West Yorkshire Eastern
Concerns raised5
1. Failure to maintain a trained and experienced reserve of custody staff for rapid deployment
2. Failure to communicate outstanding investigations or treatment to police after a patient self-discharges
3. Failure to recruit suitably capable custody staff
1. Inadequate custody staffing levels during periods of high demand
2. Lack of comprehensive knowledge of custody law and procedures among custody staff
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

Adam RICE · 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

Adam RICE was taken to hospital after being found asleep in a skateboard park, later self-discharged without a CT head scan, and was subsequently detained at a police station after being arrested. He exhibited signs of alcohol withdrawal, collapsed and died in his cell on 12 May 2014. The report identified concerns about communication between hospital staff and police, custody staffing and training, welfare checks, observation levels, handovers and monitoring practices.

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 James's University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain a trained and experienced reserve of custody staff for rapid deployment
Wider context from the report
“3b To ensure that they have a bank of staff who might ordinarily be engaged in other duties but who are trained and have experience in Custody work who can be drafted in at short notice during such periods of high demand when it becomes obvious that the existing staff cannot cope with the demands being placed upon them. ”
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 James's University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate outstanding investigations or treatment to police after a patient self-discharges
Wider context from the report
“1. When a patient self-discharges against medical advice and it is known or it is highly likely that the Police will immediately thereafter become involved and it can be foreseen that the patient will be taken into Custody. 2. Then the Clinician(s) involved should inform the Police that the person has self-discharged against advice and should give brief details of any desired and outstanding investigations or treatment (eg. Reference to a possible head injury would suffice and the desire to carry out a CT head scan). This I suggest would not breach patient confidentiality. ”
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 James's University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to recruit suitably capable custody staff
Wider context from the report
“2. That West Yorkshire Police only recruit Custody staff of the highest calibre to carry out this vital role involving some of the most vulnerable members of society. ”
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 James's University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inadequate custody staffing levels during periods of high demand
Wider context from the report
“3a To ensure that there are adequate staffing levels of all ranks and grades to fulfil this vital role particularly during periods of high demand when it is known that Custody facilities will be extremely busy and in particular on Fridays, Saturdays and Sundays. ”
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 James's University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of comprehensive knowledge of custody law and procedures among custody staff
Wider context from the report
“1. To ensure that Custody staff to which I mean Police Officers of all ranks, Civilian Detention Officers and Nursing staff have a full and comprehensive knowledge of the Police and Criminal Evidence Act and the relevant Codes of Practice and the relevant provisions of the College of Policing Authorised Professional Practice Provisions in respect of Detention and Custody and Custody Management Planning. ”
Open source report
1 Mar2016
West Yorkshire Eastern
Concerns raised1
1. Failure to record complete cardiac surgical anatomy and operative techniques in surgical notes
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

Max James Haigh · 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

Max Haigh, who had a complex congenital cardiac defect and had undergone cardiac surgery, became unwell with vomiting and deteriorated in hospital. He died on 12 June 2013 after unsuccessful resuscitation; concerns were raised that the surgeon’s operative note lacked potentially vital information for any future surgery.

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 James's University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to record complete cardiac surgical anatomy and operative techniques in surgical notes
Wider context from the report
“(1) Following surgery the surgeon prepared a note of his operation for the medical records. It was anticipated that Max may, in the future, require further surgery. The note of the surgery was unsatisfactory and failed to set out:- (a) The position of the ventricular septal defect (”VSD”) and how it was enlarged; (b) A full description of the VSD; (c) The position of the tricuspid valve; (d) The techniques that were used by the surgeon himself. (2) There is a real concern that any other surgeon performing surgery in the future faced with inadequate surgical notes would be deprived of potentially vital information to assist in the forthcoming surgery. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised5

Failure to maintain a trained and experienced reserve of custody staff for rapid deployment

Failure to communicate outstanding investigations or treatment to police after a patient self-discharges

Failure to recruit suitably capable custody staff

Inadequate custody staffing levels during periods of high demand

Lack of comprehensive knowledge of custody law and procedures among custody staff

Concerns raised1

Failure to record complete cardiac surgical anatomy and operative techniques in surgical notes