Concerns raised 8 Insufficient medication verification during care-needs assessment View source Failure to prevent administration of GP-discontinued medication View source Failure to follow up medication incidents for learning affecting vulnerable patients View source Failure to provide complete current medication and stop-date information during care handover View source Failure to transfer all prescribed medication into the electronic MAR and cross-check it at agency handover View source Inaccurate or incomplete recording of medication administration View source Failure to liaise with the community pharmacy about regularly dispensed medication View source Risk of discontinued or essential seizure-control medication being incorrectly administered View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Malcolm FISHER · 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
John Malcolm Fisher was admitted to hospital on 22 April 2025 with persistent focal seizures that developed into status epilepticus, and he died on 4 May 2025 after the seizures could not be controlled. The report raises concerns about inaccurate or incomplete medication information during transfers between community services and the omission of sodium valproate from the care agency’s medication record, resulting in six days without that medication.
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 Sussex Community NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient medication verification during care-needs assessment
Wider context from the report “4) Coastal Homecare confirmed that an assessment of needs was carried out on 15 April 2025 by a supervisor attending Mr Fisher's home address. The UCR handwritten medication forms were used to digitally record the required medications into the Coastal Homecare electronic system. Initially I was told that photographs of the medication were taken as well but on checking no photographs could be recovered save one of skin creams . It is apparently not standard practice for photographs to be taken during this kind of assessment but during the inquest it was agreed this would be good practice in future to achieve greater clarity for daily carers who frequently change.
” 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 Sussex Community NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent administration of GP-discontinued medication
Wider context from the report “1) I heard evidence from Mr Fisher's GP practice (Trinity Medical Centre) that they received a letter from Brighton Urgent Community Response (UCR) team indicating that they had, in turn, received a referral from the local Adult Social Care Team requesting a package of care assessment on 8 April. This assessment was carried out on 9 April and from handwritten medication administrative records (MAR) complied by the UCR Team from Brighton hospital, support was provided to Mr Fisher until 15 April. According to the UCR records this apparently included phenobarbital tablets twice a day even though Mr Fisher's GP had discontinued the phenobarbital on 8 April 2025 . 3 liquid AEDs were also given including sodium valproate.
” 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 Sussex Community NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up medication incidents for learning affecting vulnerable patients
Wider context from the report “6) Coastal Homecare management then self-reported the incident to the local Adult Safeguarding Team and also the Care Quality Commission but at the time of the inquest there has been no follow-up by either organisation to ascertain if there are any lessons to learn for the benefit of other vulnerable 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 Sussex Community NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide complete current medication and stop-date information during care handover
Wider context from the report “3) UCR then arranged for a care agency, Coastal Homecare, to take over supporting Mr Fisher. During the inquest I saw a referral from prepared by UCR confirming that Coastal Homecare were required to assist Mr Fisher three times a day to help with his personal care and medicine administration. However, the only medication information that was supplied by the UCR team to Coastal Homecare referred to blister packs and liquid medication including antibiotics for chest infection. No further details of current regular medication, dosage, timing or form of medication (eg blister pack, separate boxes or liquids) were provided at all. In addition, the antibiotics were only for a short number of days but no clear indication is given when they were to stop and may well have finished by the time Coastal took over 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 Sussex Community NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer all prescribed medication into the electronic MAR and cross-check it at agency handover
Wider context from the report “5) Coastal Healthcare indicated that a mistake was made when documenting the medications in that although the UCR handwritten forms included sodium valproate oral solution, this was not added at all into the Coastal Homecare electronic MAR chart . As a result, Coastal Homecare accepted that between 16 April to 21 April (6 days) Mr Fisher did not receive any sodium valproate oral solution. This was one of three liquid antiepileptic drugs Mr Fisher should have received to help control possible seizures. This mistake was not spotted at all and there is no system in place to cross check what has previously been given when there is a handover between different care agencies nor was there any liaison with the community pharmacy who regularly dispensed Mr Fisher's medication.
” 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 Sussex Community NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate or incomplete recording of medication administration
Wider context from the report “2) It is far from clear whether the UCR records are accurate regarding whether phenobarbital was given or not. The handwritten evidence says it was given but not whether this was from a blister pack or a separate box. Mr Fisher’s community pharmacist gave evidence that for some years he had dispensed phenobarbital in a separate box and not in a blister pack.
” 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 Sussex Community NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to liaise with the community pharmacy about regularly dispensed medication
Wider context from the report “5) Coastal Healthcare indicated that a mistake was made when documenting the medications in that although the UCR handwritten forms included sodium valproate oral solution, this was not added at all into the Coastal Homecare electronic MAR chart. As a result, Coastal Homecare accepted that between 16 April to 21 April (6 days) Mr Fisher did not receive any sodium valproate oral solution. This was one of three liquid antiepileptic drugs Mr Fisher should have received to help control possible seizures. This mistake was not spotted at all and there is no system in place to cross check what has previously been given when there is a handover between different care agencies nor was there any liaison with the community pharmacy who regularly dispensed Mr Fisher's medication .
” 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 Sussex Community NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of discontinued or essential seizure-control medication being incorrectly administered
Wider context from the report “Overall, after hearing evidence over two days regarding the administration of Mr Fisher's AED medication, I remain concerned that patients in the community are at risk of either being given medication that has been discontinued by a GP or not being given essential medication to control seizures .
” Open source report
×
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 Strengthen escalation pathways by referring complex medicines-reconciliation issues to senior clinicians and SCFT pharmacy support.
Verbatim wording from the response “• Clear escalation pathways have been strengthened, including referral to senior clinicians and SCFT pharmacy support for complex medicines reconciliation.” Source location Response from Sussex Community NHS Foundation Trust
Open published response
×
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 Provide staff with Plexus shared-care-record access for real-time GP medication summaries.
Verbatim wording from the response “• Since October 2025, SCFT staff have access to shared care records via the Plexus system (which links digital care records across Sussex GP’s, hospital and community healthcare services as well as local authorities), enabling real-time access to GP medication summaries and reducing reliance on emailed or static information.” Source location Response from Sussex Community NHS Foundation Trust
Open published response
×
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 and implement UCR referral documentation to require receiving agencies to reconcile medicines with prescribers and pharmacies and clarify that UCR MAR charts are for SCFT staff only.
Verbatim wording from the response “• UCR referral documentation is being revised to clearly reinforce current agreements that receiving care agencies must undertake their own medicines reconciliation directly with the prescriber and community pharmacy.” Source location Response from Sussex Community NHS Foundation Trust
Open published response
×
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 Conduct a themed review of UCR medication incidents involving MAR charts and report findings through Trust governance structures.
Verbatim wording from the response “• A themed review of medication incidents involving MAR charts within UCR is underway to inform ongoing quality improvement, training, and assurance.” Source location Response from Sussex Community NHS Foundation Trust
Open published response
×
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 Strengthen referral-pathway expectations that medicines reconciliation is confirmed when care responsibility transfers.
Verbatim wording from the response “• SCFT has strengthened expectations within referral pathways that medicines reconciliation must be confirmed at transitions of care, particularly where responsibility for medicines administration is transferring.” Source location Response from Sussex Community NHS Foundation Trust
Open published response
×
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 Update the MAR chart SOP with guidance on discontinued medicines remaining in patients’ homes and mandatory GP second checks for discrepancies.
Verbatim wording from the response “• The SOP is being updated to include explicit guidance on the management of recently discontinued medications that remain physically present in the home, including a mandatory second check with the GP where discrepancies arise.” Source location Response from Sussex Community NHS Foundation Trust
Open published response
×
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 Complete a formal review of the MAR chart SOP for UCR and Home First services.
Verbatim wording from the response “Action taken and planned:” Source location Response from Sussex Community NHS Foundation Trust
Open published response
×
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 staff briefings and training aligned with the revised MAR chart SOP after approval.
Verbatim wording from the response “• The SOP is being updated to include explicit guidance on the management of recently discontinued medications that remain physically present in the home, including a mandatory second check with the GP where discrepancies arise.” Source location Response from Sussex Community NHS Foundation Trust
Open published response
×
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 Embed pharmacy support within the UCR and General Virtual Ward model for complex or unclear medication regimes.
Verbatim wording from the response “• Pharmacy support is now embedded within the UCR/General Virtual Ward model, providing timely expert advice where medication regimes are complex or unclear.” Source location Response from Sussex Community NHS Foundation Trust
Open published response
×
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 Receiving care agencies are responsible for medicines reconciliation with prescribers and pharmacies; SCFT MAR charts are not definitive records for external providers.
Verbatim wording from the response “• UCR referral documentation is being revised to clearly reinforce current agreements that receiving care agencies must undertake their own medicines reconciliation directly with the prescriber and community pharmacy.” Source location Response from Sussex Community NHS Foundation Trust
Open published response
11 Feb 2020 Gemma Elizabeth Azhar · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 3 Failure to ensure consistent communication of the post-cancellation procedure across TTT service areas View source Failure to include the post-cancellation procedure in written policy, protocol or induction training View source Failure to provide clinical contact and assessment after repeated service cancellations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gemma Elizabeth Azhar · 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
Gemma Azhar self-referred to the Time to Talk service while experiencing long-term anxiety and depression and acute distress related to marital problems. Her assessment appointments were cancelled twice; after the second cancellation, she was discharged without an assessment of her current mental state or risk. She was later found hanging at her home, and the inquest concluded that she died by suicide. The report raised concerns that repeated cancellations and communication solely through administrators could leave people at risk, and that the relevant procedure was not consistently documented or communicated.
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 Sussex Community NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure consistent communication of the post-cancellation procedure across TTT service areas
Wider context from the report “Those in need of the TTT service and support may feel discouraged from engaging with the service and be left at risk in the community if, when repeated cancellations occur, they are spoken to only by an office administrator, who is not in any position to enquire about their mental health or make any assessment of their current condition.
Indeed ████████, the Clinical Lead for the Time to Talk service in the North Area, of gave evidence at Gemma Azhar’s inquest and informed me that in her view, the service “did not get it right”. She stated that given that the TTT service had cancelled Ms Azhar’s appointment twice, it would have been preferable if there had been attempts made to find her an alternative therapist on 30 September 2019 and, if none was available, for a duty worker to have spoken to Gemma Azhar before she was discharged from the service in order to understand: the reasons for her now declining a third appointment; her current mental state and, if appropriate, seek to engage her and assess her present risk.
████████ informed me that it was now the ‘formal’ position that this should happen after a second cancellation by the service. However, it is a matter of concern to me that staff working in the North area (Horsham, Crawley and Mid Sussex) have only been notified of this ‘formal position’ by an email sent in or around December 2019. This procedure is not part of any written policy or protocol or induction training and therefore new staff in the North area would only learn the procedure by word of mouth. Furthermore, ████████ was not aware whether or not a similar instruction had been given to the Sussex Community NHS Foundation Trust’s staff working for the TTT service in other areas.
” 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 Sussex Community NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include the post-cancellation procedure in written policy, protocol or induction training
Wider context from the report “Those in need of the TTT service and support may feel discouraged from engaging with the service and be left at risk in the community if, when repeated cancellations occur, they are spoken to only by an office administrator, who is not in any position to enquire about their mental health or make any assessment of their current condition.
Indeed ████████, the Clinical Lead for the Time to Talk service in the North Area, of gave evidence at Gemma Azhar’s inquest and informed me that in her view, the service “did not get it right”. She stated that given that the TTT service had cancelled Ms Azhar’s appointment twice, it would have been preferable if there had been attempts made to find her an alternative therapist on 30 September 2019 and, if none was available, for a duty worker to have spoken to Gemma Azhar before she was discharged from the service in order to understand: the reasons for her now declining a third appointment; her current mental state and, if appropriate, seek to engage her and assess her present risk.
████████ informed me that it was now the ‘formal’ position that this should happen after a second cancellation by the service. However, it is a matter of concern to me that staff working in the North area (Horsham, Crawley and Mid Sussex) have only been notified of this ‘formal position’ by an email sent in or around December 2019. This procedure is not part of any written policy or protocol or induction training and therefore new staff in the North area would only learn the procedure by word of mouth. Furthermore, ████████ was not aware whether or not a similar instruction had been given to the Sussex Community NHS Foundation Trust’s staff working for the TTT service in other areas.
” 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 Sussex Community NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clinical contact and assessment after repeated service cancellations
Wider context from the report “Those in need of the TTT service and support may feel discouraged from engaging with the service and be left at risk in the community if, when repeated cancellations occur, they are spoken to only by an office administrator, who is not in any position to enquire about their mental health or make any assessment of their current condition.
Indeed ████████, the Clinical Lead for the Time to Talk service in the North Area, of gave evidence at Gemma Azhar’s inquest and informed me that in her view, the service “did not get it right”. She stated that given that the TTT service had cancelled Ms Azhar’s appointment twice, it would have been preferable if there had been attempts made to find her an alternative therapist on 30 September 2019 and, if none was available, for a duty worker to have spoken to Gemma Azhar before she was discharged from the service in order to understand: the reasons for her now declining a third appointment; her current mental state and, if appropriate, seek to engage her and assess her present risk.
████████ informed me that it was now the ‘formal’ position that this should happen after a second cancellation by the service. However, it is a matter of concern to me that staff working in the North area (Horsham, Crawley and Mid Sussex) have only been notified of this ‘formal position’ by an email sent in or around December 2019. This procedure is not part of any written policy or protocol or induction training and therefore new staff in the North area would only learn the procedure by word of mouth. Furthermore, ████████ was not aware whether or not a similar instruction had been given to the Sussex Community NHS Foundation Trust’s staff working for the TTT service in other areas.
” Open source report
×
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 Create and implement a formal SOP governing service-cancelled appointments, including duty-therapist escalation after two cancellations.
Verbatim wording from the response “(1) A Standard Operating Procedure (SOP) has been created to confirm the processes to be followed when the Service has cancelled appointments. A separate, existing SOP concerning patients who do not attend or who cancel appointments has also been updated. The updated SOP ensures that cancellations of appointments by patients are identified and includes an additional digital audit system as a weekly measure to monitor numbers.” Source location 2020-0026-Response-from-Sussex-Community-NHS-Foundation-Trust-Redacted
Open published response
×
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 a digital alert process notifying senior therapists when two service appointments are cancelled without clinician contact.
Verbatim wording from the response “The new SOP will ensure that administrative staff contact the duty therapist about any patient in circumstances similar to Gemma (where two assessment appointments have been cancelled). This will enable the duty therapist to try to promote engagement and maximise the opportunity for a clinically informed conversation with the patient, with further action taken as necessary. As a further safeguarding measure, a digital alert system, coordinated by the data analysts, will provide a process which will alert senior therapists to” Source location 2020-0026-Response-from-Sussex-Community-NHS-Foundation-Trust-Redacted
Open published response
×
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 the cancellation procedures to all staff and integrate them into team training and formal induction.
Verbatim wording from the response “The SOP has been reviewed and agreed at the Team Governance Meeting and Area Governance Meeting. It has now been disseminated to all staff via the senior leadership team for each locality and has been integrated into team training and formal induction processes. It is also accessible to all staff via the service shared electronic folder system.” Source location 2020-0026-Response-from-Sussex-Community-NHS-Foundation-Trust-Redacted
Open published response
23 Mar 2015 James Bateley · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1 Lack of ready access to necessary dressings for nursing homes and Community Nurses treating pressure sores View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Bateley · 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
James Bateley was admitted to Worthing Hospital with severe pressure sores and died on 6 June 2014; the stated cause of death included bronchopneumonia, sepsis, necrotising fasciitis and a pressure wound. The report raised concern that nursing homes and community nurses did not have ready access to necessary dressings, which could take up to 14 days to arrive and meant that, in Mr Bateley’s case, staff borrowed dressings from another resident.
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 Sussex Community NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ready access to necessary dressings for nursing homes and Community Nurses treating pressure sores
Wider context from the report “During the evidence it became apparent that neither the nursing home, where Mr Bateley was living, nor the Community Nurses, who had been called in to assist in treating Mr Bateley’s pressure sores had ready access to the necessary dressings . There was evidence given that these dressings are not readily available to nursing homes or the Community Nurses who regularly have to treat this type of ailment . The dressings have to be ordered through the GP and we were told that it could take up to 14 days for them to arrive . In Mr Bateley’s case staff had to borrow and make use other resident’s dressings. Sadly Mr Bateley was taken into hospital before his dressings arrived. Whilst the absence of these dressing was unlikely to have contributed directly to Mr Bateley’s death there is concern for others in the future who cannot rely on others to borrow dressing from.
” Open source report
×
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 stock box and first-dressing system for patients beginning care.
Verbatim wording from the response “A number of immediate actions have already been taken, namely:” Source location 2015-0115-Response-by-Sussex-Community-NHS-Trust
Open published response
×
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 an escalation process for delays in dressing-supply responses.
Verbatim wording from the response “A number of immediate actions have already been taken, namely:” Source location 2015-0115-Response-by-Sussex-Community-NHS-Trust
Open published response
×
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 Roll out the ONPOS ordering service fully after the shadow period.
Verbatim wording from the response “Longer-term actions to improve this area of service are being discussed with the CCG. Once engagement and agreements are in place an ONPOS (On-Line Non Prescription Ordering Service) will be run in shadow from July for a 6-12 month period with the plan to roll this out in full from January 2016.” Source location 2015-0115-Response-by-Sussex-Community-NHS-Trust
Open published response
×
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 Run the ONPOS ordering service in shadow mode for six to twelve months.
Verbatim wording from the response “Longer-term actions to improve this area of service are being discussed with the CCG. Once engagement and agreements are in place an ONPOS (On-Line Non Prescription Ordering Service) will be run in shadow from July for a 6-12 month period with the plan to roll this out in full from January 2016.” Source location 2015-0115-Response-by-Sussex-Community-NHS-Trust
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations