25 Jul 2014 Clare Serena Anke COOPER · Prevention of Future Deaths report Surrey
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Concerns raised 14 Insufficiently detailed EDS referral information about low sodium and blood results View source Failure to consider chemical pathology flagging of particularly concerning results View source Lack of a national protocol for assessing seriously ill eating-disorder patients for an organic basis View source No established GP practice system for recognition, assessment and management of electrolyte abnormalities View source Lack of GP routine vital sign monitoring when weight loss is a concern View source Insufficient reinforcement of excluding an organic basis before psychiatric or psychological labelling View source Lack of a documented list of potential diagnoses for exclusion at eating-disorder triage View source Lack of hospital or GP notes available to the post-mortem pathologist View source Failure to robustly assess presenting signs and symptoms and consider or exclude organic causes View source Lack of understanding of hyponatraemia causes, investigation thresholds and required investigations View source Insufficient communication from referral agents to the eating disorder service View source Poor GP documentation View source Insufficiently robust EDS eating-disorder triage proforma for considering and excluding organic causes View source Insufficiently clear published guidance on the causes, investigation and treatment of low blood sodium View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Clare Serena Anke COOPER · 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
Clare Serena Anke Cooper, a young adult, developed weight loss, lassitude, dizziness, nausea, difficulty eating and an intermittently low blood sodium level before dying after a cardiorespiratory arrest and hospital admission. The inquest concluded that she died from the consequences of undiagnosed Addison’s disease and an Addisonian crisis. Principal concerns included inadequate assessment and documentation in primary care, failure to investigate the low sodium and possible physical causes, insufficient eating-disorder service triage processes, and inadequate information available for the post-mortem examination.
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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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently detailed EDS referral information about low sodium and blood results
Wider context from the report “6. Insufficiently detailed referral letter to EDS (mentioning ‘low sodium’ but not accompanied with a copy of the blood results ) and an opportunity was lost for its significance to be considered
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider chemical pathology flagging of particularly concerning results
Wider context from the report “4. No established system for recognition, assessment and management of electrolyte abnormalities within the GP practice and/or consideration of the chemical pathology service to ‘flag-up’ particularly concerning results .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a national protocol for assessing seriously ill eating-disorder patients for an organic basis
Wider context from the report “8. The lack of a national protocol for assessing patients seriously ill with an eating disorder with the possibility of detecting individuals with an organic basis for the condition .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation No established GP practice system for recognition, assessment and management of electrolyte abnormalities
Wider context from the report “4. No established system for recognition, assessment and management of electrolyte abnormalities within the GP practice and/or consideration of the chemical pathology service to ‘flag-up’ particularly concerning results.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of GP routine vital sign monitoring when weight loss is a concern
Wider context from the report “3. Lack of GP routine vital sign monitoring e.g. heart rate, blood pressure and weight measurement when weight loss is a concern with a lost opportunity to assess the severity of weight loss.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient reinforcement of excluding an organic basis before psychiatric or psychological labelling
Wider context from the report “10. The need to highlight this case nationally to clarify published guidance with regard to the causes, investigation and treatment of low blood sodium and to reinforce the importance of excluding an organic basis of an illness before labelling the condition a psychiatric or psychological disorder .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a documented list of potential diagnoses for exclusion at eating-disorder triage
Wider context from the report “7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of hospital or GP notes available to the post-mortem pathologist
Wider context from the report “9. Lack of hospital or GP notes available for the pathologist undertaking the post mortem to facilitate a greater opportunity for clinic-pathological correlation in deaths which are unascertained and a higher level of suspicion to explore rare causes of unexpected death, especially in the young.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to robustly assess presenting signs and symptoms and consider or exclude organic causes
Wider context from the report “2. Lack of evidence of a robust assessment of presenting signs and symptoms with a presumption of a psychological/psychiatric problem without considering or excluding an organic cause .
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of hyponatraemia causes, investigation thresholds and required investigations
Wider context from the report “5. Lack of understanding of the underlying causes of hyponatraemia (consistently or intermittently low) and the level below which will require further investigation, and the investigations that should be carried out , particularly in circumstances when there is no obvious cause of the low sodium.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication from referral agents to the eating disorder service
Wider context from the report “7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor GP documentation
Wider context from the report “1. Poor GP documentation
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust EDS eating-disorder triage proforma for considering and excluding organic causes
Wider context from the report “7. Insufficiently robust EDS proforma used to triage patients for an eating disorder: lack of prompts and a need to emphasise and exclude organic causes, however rare. The lack of a documented list of potential diagnoses to be assessed and excluded at triage, including organic causes. A need to facilitate communication from the referral agents to the eating disorder service.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently clear published guidance on the causes, investigation and treatment of low blood sodium
Wider context from the report “10. The need to highlight this case nationally to clarify published guidance with regard to the causes, investigation and treatment of low blood sodium and to reinforce the importance of excluding an organic basis of an illness before labelling the condition a psychiatric or psychological disorder.
” 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 Deliver a Trust-wide academic teaching session for Eating Disorder Service clinical staff on Addison’s disease, hyponatremia, and thresholds for further investigation.
Verbatim wording from the response “We acknowledge the importance of increasing knowledge and awareness within the Eating Disorder Service about possible causes of hyponatremia and when to seek further investigations. We will be addressing this need through a Trust-wide eating disorders academic meeting during which there will be a teaching session for all clinical staff specifically about presenting symptoms and signs of Addison’s disease including psychological manifestations, causes of hyponatremia and circumstances/levels below which further investigation should actioned.” Source location 2014-0345-Response-by-Surrey-Borders-Partnership-NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue supporting the Medical Records Team to ensure key records are provided promptly to pathologists.
Verbatim wording from the response “closely with all interested parties to share clinical records including the Coroner and the pathologists. In this incident we shared records with the family (including the professional witness) and our Medical Records Team was in constant communication with them about access to records, but we are unable to find any information about any delays or issues with making these records available to the pathologist. We have shared this concern with our Medical Records Team and we will continue to support them in ensuring that all key records are made available in a timely manner to the pathologist in the future.” Source location 2014-0345-Response-by-Surrey-Borders-Partnership-NHS
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 Share the concern about timely provision of clinical records with the Medical Records Team.
Verbatim wording from the response “closely with all interested parties to share clinical records including the Coroner and the pathologists. In this incident we shared records with the family (including the professional witness) and our Medical Records Team was in constant communication with them about access to records, but we are unable to find any information about any delays or issues with making these records available to the pathologist. We have shared this concern with our Medical Records Team and we will continue to support them in ensuring that all key records are made available in a timely manner to the pathologist in the future.” Source location 2014-0345-Response-by-Surrey-Borders-Partnership-NHS
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 Revise the GP referral form to require information supporting assessment and exclusion of organic causes before eating-disorder referral.
Verbatim wording from the response “We have revised our referral form in order to try and improve the quality of information that GPs provide when referring patients. The form asks for more detail from the GP including that they consider and exclude organic causes of weight loss prior to making a referral to the Eating Disorders Service. The form also highlights the need for the GP to provide further details of the nature of the eating problem, results of blood investigations, physical examination and past medical history so that all information is available prior to assessment by the Eating Disorders Service.” Source location 2014-0345-Response-by-Surrey-Borders-Partnership-NHS
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 Revise the eating-disorder triage form to record investigations, physical findings, symptoms, medical history, and potential organic causes.
Verbatim wording from the response “We have however reviewed our triage form to ensure that all information including physical investigations is recorded in one form. The changes made include:” Source location 2014-0345-Response-by-Surrey-Borders-Partnership-NHS
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 GPs are expected to consider and exclude organic causes before referring patients to the Eating Disorders Service.
Verbatim wording from the response “We have revised our referral form in order to try and improve the quality of information that GPs provide when referring patients. The form asks for more detail from the GP including that they consider and exclude organic causes of weight loss prior to making a referral to the Eating Disorders Service. The form also highlights the need for the GP to provide further details of the nature of the eating problem, results of blood investigations, physical examination and past medical history so that all information is available prior to assessment by the Eating Disorders Service.” Source location 2014-0345-Response-by-Surrey-Borders-Partnership-NHS
Open published response
16 Dec 2013 Sarah Anne Shepherd · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Unclear alignment of resuscitation training with current guidance View source Failure to initiate resuscitation when a patient is not breathing normally View source Failure to establish a clear referral process to the Psychiatric Intensive Care Unit View source Failure to include required observations and recording in resuscitation training View source Failure to require written and reasoned referral responses and their recording in patient notes View source Misleading resuscitation aide memoires in staff resuscitation bags View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sarah Anne Shepherd · 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
Sarah Anne Shepherd, a patient detained under the Mental Health Act, was found in her room with a plastic bin liner over her head on 12 September 2011 and died in hospital the following day. The report identified concerns about unclear referral processes to the Psychiatric Intensive Care Unit, failures to attempt resuscitation in accordance with guidance, and uncertainty and misleading materials concerning resuscitation training.
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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear alignment of resuscitation training with current guidance
Wider context from the report “(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council. They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally”.
The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded.
Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally”.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to initiate resuscitation when a patient is not breathing normally
Wider context from the report “(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council . They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally” .
The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded.
Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally”.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish a clear referral process to the Psychiatric Intensive Care Unit
Wider context from the report “(1) It was clear from the evidence that the Trust has in place an Operational Policy concerning its Psychiatric Intensive Care Services. The Policy in place in September 2011 did not establish a clear process for the referral of an inpatient from an acute ward (or any other patient) to the Psychiatric Intensive Care Unit and it did not require the PICU to provide a written and reasoned response to the referral and to record the same on the patient’s RIO (or other medical) notes. From the evidence heard, it does not seem that these concerns have yet been addressed or sufficiently addressed by amendment of the Operational Policy and consequential staff training.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include required observations and recording in resuscitation training
Wider context from the report “(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council. They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally”.
The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded .
Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally”.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to require written and reasoned referral responses and their recording in patient notes
Wider context from the report “(1) It was clear from the evidence that the Trust has in place an Operational Policy concerning its Psychiatric Intensive Care Services. The Policy in place in September 2011 did not establish a clear process for the referral of an inpatient from an acute ward (or any other patient) to the Psychiatric Intensive Care Unit and it did not require the PICU to provide a written and reasoned response to the referral and to record the same on the patient’s RIO (or other medical) notes . From the evidence heard, it does not seem that these concerns have yet been addressed or sufficiently addressed by amendment of the Operational Policy and consequential staff training.
” 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 Surrey and Borders Partnership NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Misleading resuscitation aide memoires in staff resuscitation bags
Wider context from the report “(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council. They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally”.
The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded.
Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally” .
” Open source report
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