18 Apr 2024 ALEXANDER LEE REID · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1 Failure of general practice IT systems to validate or challenge potential data input errors at the point of entry View source
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ALEXANDER LEE REID · 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
Alexander Lee Reid received the Oxford AstraZeneca Covid-19 vaccine after being invited early because an erroneous BMI in his GP records led him to be identified as vulnerable. He died on 29 June 2021, and the inquest concluded that his death was linked to the vaccination, with the medical cause recorded as cerebral venous sinus thrombosis and Covid-19 vaccine-induced immune thrombotic thrombocytopenia. The principal concern was whether general practice IT systems should validate or challenge potentially erroneous data at the point of entry to improve data reliability and patient safety.
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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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of general practice IT systems to validate or challenge potential data input errors at the point of entry
Wider context from the report “(2) The inquest heard expert evidence that the combined vaccination monitoring and recall specification designed to identify vulnerable people for the purposes of inviting them to receive their Covid vaccinations early had identified Alex as vulnerable from an incorrect BMI of 68.97 recorded in his GP records on 06/02/2004. The mistake was due to the relevant clinician recording Alex's height as 145cm and his weight as 145kg, giving a BMI of 68.97 for an 11 year old boy whose previously recorded BMI aged 9 had been 14.88.
(3) The inquest heard expert evidence that to have built a system that would validate multiple data items in an individual's GP records for the purposes of ensuring that individuals were not incorrectly identified as vulnerable would not have been feasible within the constraints and context of the Covid-19 programme.
(4) The inquest heard expert evidence that an easier and more appropriate option would be to embed validation rules in general practice IT systems that would check such information at the time of data entry .
(5) If the obviously erroneous BMI had not been recorded or had been challenged at the point of entry by the relevant IT system, Alex would not have been classed as vulnerable, would not have been offered a vaccine before guidance was published that the under 30’s should not receive the Oxford Astra Zeneca vaccine, and would not have died when he did.
(6) The consequences of the data input error in this case give rise to a concern that more might be done by way of specification design to allow for the correction of or challenge to potential data input errors at the point of entry , with consequential improvements in the reliability of such data and the safety of patients and reducing the risk of other deaths occurring in similar circumstances in the future.
” 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 Maintain point-of-entry validation restricting extreme height, weight and calculated BMI values in SystmOne.
Verbatim wording from the response “In SystmOne, there is already validation at the point of entry on height and weight measurements to prevent extreme values being entered. For example, a maximum height of 3 metres can be entered, with the maximum weight being 500 kilograms. Similarly, a calculated BMI is constrained to between 0 and 150. It is not impossible, however, for someone to have a BMI as high as the one that was calculated in this instance. Thus the system must allow such a BMI to be accurately recorded if this is the true calculated BMI.” Source location Response from TPP
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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 Contact NHS England separately about validation of calculated BMI data in GP IT systems.
Verbatim wording from the response “To return to the specific concern that could be directed to GP system suppliers, should NHS England decide that it would be appropriate to include validation concerning the calculation of BMIs in GP IT systems, the requirements for this would be most appropriately set at a national level to ensure a consistent approach across all GPs. Of course, in the clinical environment there are already a number of alerts, flags, prompts and notifications directed at clinical staff, and consideration would need to be taken to the sensitivity of the validation to ensure this is not triggered so frequently as to cause ‘alert fatigue’.” Source location Response from TPP
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Any additional BMI validation requirements should be set nationally by NHS England to ensure consistency across GP systems.
Verbatim wording from the response “To return to the specific concern that could be directed to GP system suppliers, should NHS England decide that it would be appropriate to include validation concerning the calculation of BMIs in GP IT systems, the requirements for this would be most appropriately set at a national level to ensure a consistent approach across all GPs. Of course, in the clinical environment there are already a number of alerts, flags, prompts and notifications directed at clinical staff, and consideration would need to be taken to the sensitivity of the validation to ensure this is not triggered so frequently as to cause ‘alert fatigue’.” Source location Response from TPP
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SystmOne already validates height, weight and BMI ranges, and must permit unusually high BMI values when clinically accurate.
Verbatim wording from the response “In SystmOne, there is already validation at the point of entry on height and weight measurements to prevent extreme values being entered. For example, a maximum height of 3 metres can be entered, with the maximum weight being 500 kilograms. Similarly, a calculated BMI is constrained to between 0 and 150. It is not impossible, however, for someone to have a BMI as high as the one that was calculated in this instance. Thus the system must allow such a BMI to be accurately recorded if this is the true calculated BMI.” Source location Response from TPP
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22 Mar 2024 Finlay Stuart Ian FINLAYSON · Prevention of Future Deaths report East Sussex
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Concerns raised 2 Failure to reliably transfer key medical information between incompatible systems View source Delays in transferring medical information to prison healthcare staff View source
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Finlay Stuart Ian FINLAYSON · 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
Finlay Stuart Ian FINLAYSON died following cardiac arrest at HMP Lewes on 25 January 2019; the stated causes were pulmonary thromboemboli due to deep vein thrombosis, against a background of metastatic carcinoma of the base of the tongue. Concerns included delays and possible omissions in transferring medical information between healthcare systems, poor record keeping, communication failures, delays in accessing healthcare, and failures in the emergency response.
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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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably transfer key medical information between incompatible systems
Wider context from the report “During the course of the Inquest the jury heard evidence about the difficulty in information being transferred over from Mr Finlayson's GP surgery system, which uses SystmOne to the prison system (also SystmOne). The evidence was that information was not able to be freely shared between the two and it meant that there was a delay in healthcare staff in the prison accessing relevant information about Mr Finlayson's long term health issues as well as contact with his GP as recent as a week before going in to prison.
Mr Finlayson sadly died in 2019 and I have heard evidence that the functioning of SystmOne has improved since his death. I was told, however, that there remains an issue with the interaction between SystmOne and other medical databases used in England and Wales. SystmOne appears to be the preferred system for many prisons and detention centres but there are still many GP surgeries that use other systems.
I heard evidence that if someone goes to prison and is linked to a surgery that uses another system (like EMIS) the notes have to be printed and scanned on to SystmOne and key information has to be input onto someone's record by hand .
I am concerned about the potential delay this process could cause. I am also concerned that key information could be missed by virtue of these systems not communicating with each other . I have heard evidence as to the importance of someone's medical history being available for those within the prison setting to assist with careplanning and the provision of appropriate care and in my opinion, there is a risk that future deaths could occur unless action is taken to make the transfer of this information more efficient.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring medical information to prison healthcare staff
Wider context from the report “During the course of the Inquest the jury heard evidence about the difficulty in information being transferred over from Mr Finlayson's GP surgery system, which uses SystmOne to the prison system (also SystmOne). The evidence was that information was not able to be freely shared between the two and it meant that there was a delay in healthcare staff in the prison accessing relevant information about Mr Finlayson's long term health issues as well as contact with his GP as recent as a week before going in to prison.
Mr Finlayson sadly died in 2019 and I have heard evidence that the functioning of SystmOne has improved since his death. I was told, however, that there remains an issue with the interaction between SystmOne and other medical databases used in England and Wales. SystmOne appears to be the preferred system for many prisons and detention centres but there are still many GP surgeries that use other systems.
I heard evidence that if someone goes to prison and is linked to a surgery that uses another system (like EMIS) the notes have to be printed and scanned on to SystmOne and key information has to be input onto someone's record by hand.
I am concerned about the potential delay this process could cause . I am also concerned that key information could be missed by virtue of these systems not communicating with each other. I have heard evidence as to the importance of someone's medical history being available for those within the prison setting to assist with careplanning and the provision of appropriate care and in my opinion, there is a risk that future deaths could occur unless action is taken to make the transfer of this information more efficient.
” 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 Enable functionality supporting automatic electronic transfer of prisoners’ full community GP records to prison GPs and back on release.
Verbatim wording from the response “Since the time of Mr Finlayson’s death, more has been done to improve matters. Full GP registration (‘GMS’) has been introduced into prisons in the last two years as a result of policy change by NHS England. Functionality was enabled by TPP to enact this policy change. As a result, prisoners can now opt to have their community GP registration (and their community GP record) transferred to the prison GP. This involves the automatic electronic transfer of the full community GP record to the prison GP, which is then transferred out again on release of the prisoner to the community GP practice. This is an enormous improvement. This change applies regardless of whether the community GP practice uses SystmOne or EMIS.” Source location Response from TPP
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation GP data controllers are responsible for permitting data sharing and enabling the relevant reciprocal controls under data protection legislation.
Verbatim wording from the response “Your report highlights that information was not freely shared between the GP (using SystmOne) and the prison service. Functionality to allow seamless sharing of data is available within SystmOne, and this functionality was available to the detained estate (including prisons) from well before 2019. However, as is still the case, the sharing of data is dependent on the data controller (in this case the GP) permitting the data to be made available to other healthcare organisations. This responsibility is set out in UK Data Protection Legislation. Without the control in SystmOne being turned on by the GP data controller (and a reciprocal control on the receiving side being enabled) the data is not visible. Dame Fiona Caldicott and other data champions have tried to make information sharing ‘the norm’ but there is still resistance in many areas.” Source location Response from TPP
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15 Mar 2023 Jai SINGH · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 11 Failure to meaningfully engage with families and consider family concerns View source Poor record keeping within and between teams View source Failure to recognise the significance of reported psychotic symptoms and provide adequate assessment and treatment View source Absence of a rolling risk assessment facility in SystemOne View source Absence of ongoing risk assessment documentation for patients with mental illness in SystemOne View source Failings in use of the ACCT system View source Failure to identify the need for inpatient admission and assessment for secure transfer View source Delays in taking patients onto the mental health caseload and providing allocated CPN and MDT oversight View source Failure to use interpreters View source Absence of a psychiatrist from the mental health MDT View source Poor communication within and between teams View source See 8 more concerns
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Jai SINGH · 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
Jai Singh died at City Hospital on 28 January 2022 after being found in cardiac arrest in his cell at HMP Birmingham, having asphyxiated after placing a bag over his head. The report identifies repeated failures to communicate and record family and clinical concerns, use interpreters, assess risk, operate the ACCT process, and provide appropriate mental-health admission and transfer. It also identifies ongoing risks from the absence of a psychiatrist in the prison mental-health MDT and the lack of ongoing risk-assessment documentation in SystemOne.
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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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to meaningfully engage with families and consider family concerns
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters, poor communication and record keeping within and between teams, the absence of meaningful engagement with Mr. Singh's family , insufficient consideration of family concerns and failings in the use of the ACCT system.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Poor record keeping within and between teams
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters, poor communication and record keeping within and between teams , the absence of meaningful engagement with Mr. Singh's family, insufficient consideration of family concerns and failings in the use of the ACCT system.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the significance of reported psychotic symptoms and provide adequate assessment and treatment
Wider context from the report “4. In Mr. Singh's case it is my conclusion that it is likely that if a psychiatrist had been at a mental health MDT meeting held on the 19th January 2022 they would have identified that he needed to be admitted to ward 2 without further delay. At the very least the need for urgent review by a psychiatrist and CPN would have been recognised and facilitated which would in turn have lead to admission. CPNs in Mr. Singh's case continually failed to identify the significance of repeatedly and consistently reported psychotic symptoms and consequently he did not receive adequate assessment and treatment which increased his risk of self harm and suicide which in turn was not sufficiently identified. The absence of a psychiatrist at the MDT creates a risk that the significance of some symptoms and presentations will not be recognised and further deaths could occur due to lack of appropriate assessment and treatment.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Absence of a rolling risk assessment facility in SystemOne
Wider context from the report “5. Other electronic health care records systems used in mental health settings have a rolling risk assessment document that clinicians are required to review and update at certain points in a patient's management. The risk assessment document provides a prompt to clinicians to formally consider risk and come to a reasoned, documented conclusion that then feeds into decision making. The record also provides a reliable, easily accessible source of risk history. No such facility is in use on SystemOne at HMP Birmingham . Further, the evidence given was that once a system is not being used routinely across mental health care within the prison estate and is not provided as standard on SystemOne. This creates an ongoing risk to life arising from under-estimation of risk as a result of clinicians not formally considering and assessing current risk levels, and salient risk history not being easily accessible . It is understood by Birmingham and Solihull Mental Health Trust that it should be possible to create a specific risk assessment record within SystemOne and this is being considered locally. However, the evidence given was that this issue should be highlighted nationally and that the developers and distributors of SystemOne should be involved so as to ensure the best available solution is identified.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Absence of ongoing risk assessment documentation for patients with mental illness in SystemOne
Wider context from the report “3. However, there are two features of the mental health care provided to Mr. Singh that create a risk to the lives of others that have not yet been rectified:
i. the fact that the mental health team multi-disciplinary team (MDT) does not include a psychiatrist; and
ii. the absence of any ongoing risk assessment documentation for patients with mental illness within the SystemOne records at HMP Birmingham .
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failings in use of the ACCT system
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters, poor communication and record keeping within and between teams, the absence of meaningful engagement with Mr. Singh's family, insufficient consideration of family concerns and failings in the use of the ACCT system .
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the need for inpatient admission and assessment for secure transfer
Wider context from the report “2. Much of the evidence at the inquest focused on the central issue of repeated missed opportunities to identify that Mr. Singh required admission to the prison's inpatient ward, ward 2, and assessment for section 48 transfer to a medium secure unit (which would have been likely to result in transfer to a medium secure unit). The consequences of the failure to transfer Mr. Singh to an inpatient setting were compounded by the fact that he was not taken onto the mental health team's caseload promptly and therefore did not have the benefit of an allocated CPN and the oversight and input of a mental health multi-disciplinary team. Many steps have been undertaken by Birmingham and Solihull Mental Health Trust (who provide mental health services within the prison) to minimise the risk of such a situation occurring again.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Delays in taking patients onto the mental health caseload and providing allocated CPN and MDT oversight
Wider context from the report “2. Much of the evidence at the inquest focused on the central issue of repeated missed opportunities to identify that Mr. Singh required admission to the prison's inpatient ward, ward 2, and assessment for section 48 transfer to a medium secure unit (which would have been likely to result in transfer to a medium secure unit). The consequences of the failure to transfer Mr. Singh to an inpatient setting were compounded by the fact that he was not taken onto the mental health team's caseload promptly and therefore did not have the benefit of an allocated CPN and the oversight and input of a mental health multi-disciplinary team . Many steps have been undertaken by Birmingham and Solihull Mental Health Trust (who provide mental health services within the prison) to minimise the risk of such a situation occurring again.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to use interpreters
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters , poor communication and record keeping within and between teams, the absence of meaningful engagement with Mr. Singh's family, insufficient consideration of family concerns and failings in the use of the ACCT system.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Absence of a psychiatrist from the mental health MDT
Wider context from the report “3. However, there are two features of the mental health care provided to Mr. Singh that create a risk to the lives of others that have not yet been rectified:
i. the fact that the mental health team multi-disciplinary team (MDT) does not include a psychiatrist ; and
ii. the absence of any ongoing risk assessment documentation for patients with mental illness within the SystemOne records at HMP Birmingham.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Poor communication within and between teams
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters, poor communication and record keeping within and between teams, the absence of meaningful engagement with Mr. Singh's family, insufficient consideration of family concerns and failings in the use of the ACCT system.
” Open source report
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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 SystmOne is working correctly and safely from a system perspective.
Verbatim wording from the response “From a system perspective I am confident that SystmOne is working correctly and in a safe manner.” Source location Response from TPP
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The system commissioner decides whether and how to use SystmOne templates, decision support, alerts, reminders and warnings.
Verbatim wording from the response “SystmOne provides our users with many tools to support patient care – the creation of data entry templates, the development of decision support for particular circumstances, and the ability to produce alerts, reminders and warnings as data is entered. The decision to use these, and how they should be used is in the hands of the commissioner of the system. Professor Powis’ report details how the system is used for mental health assessments.” Source location Response from TPP
Open published response
20 Dec 2022 Alexander Michael BRAUND · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 6 Failure to consistently apply NEWS2 assessment and monitoring, supported by adequate training and guidance View source Failure of NEWS2 compliance auditing to reliably monitor adherence View source Absence of an agreed joint care plan for acutely unwell prisoners remaining in prison View source Unclear cell-entry criteria for prison officers during life-threatening emergencies View source Misunderstanding among discipline staff of medical emergency code criteria View source Failure to clearly flag amendments to SystmOne medical records View source See 3 more concerns
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AI-generated summary
Alexander Michael BRAUND · 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
Alexander Michael Braund was a 25-year-old remand prisoner at HMP Nottingham who became acutely unwell with an undetected atypical pneumonia and died on 10 March 2020 after cardiac arrest and withdrawal of life support. The principal concerns included failures in NEWS2 assessment and monitoring, the absence of a joint healthcare and prison-staff care plan, delays in entering his cell and calling a medical emergency code, and potential weaknesses in the integrity of amended electronic medical records.
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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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently apply NEWS2 assessment and monitoring, supported by adequate training and guidance
Wider context from the report “1.(HEALTHCARE) Lack of safe system, supported by training, guidance, and compliance auditing, for the provision of physical healthcare assessment and monitoring by NEWS2 for acutely unwell patients in a secure setting.
The Jury found shortcomings in the healthcare afforded to Alex at HMP Nottingham in the form of "continuous failures to provide adequate healthcare, which probably more than minimally contributed to his death".
I heard evidence that staff were not consistently assessing acutely unwell patients using the NEWS2 system , despite the scoring system having been adopted across the NHS over the past decade and having been adopted by this Trust many years prior.
In 2017, when relaunching the NEWS system, the Royal College of Physicians noted, "Every so often, someone comes up with an idea that is so obvious, no one can understand why it wasn’t thought of before. I am proud that the RCP’s National Early Warning Score (NEWS) is one of those initiatives – not just a chart (or iPad) at the end of the bed to record the patient’s physical signs and symptoms, but the chart at the end of the bed – a single point of truth to unify recording of symptoms across the NHS, consolidate training for doctors and nurses in the recording of symptoms, and thereby improve patient safety. When the RCP launched the NEWS in 2012, we hoped to see the score adopted across the NHS. What has been more astonishing is the adoption of the score internationally, with requests to use NEWS coming from health services across the world from Europe to India and the USA, including the US Naval Air Forces!"
I heard evidence of an inconsistent application of NEWS2 by staff, an inconsistent awareness of NEWS2 across the staff body, and an absence of clear and robust training supported by guidance , ensuring staff were aware of the expectations of their employer with regards to the use of NEWS2 in monitoring acutely unwell patients.
Sadly, Alex’s is not an isolated case. I have been repeatedly assured at a senior level from Nottinghamshire Healthcare NHS Foundation Trust that they are seeking to embed NEWS2 across their Directorates, yet successive inquests have heard of patients failed by the lack of use of the system by the clinical staff responsible for their medical care. If this issue is not addressed across the Trust, with sufficient urgency, patients will continue to die in Trust settings due to a failure to recognise the deteriorating patient, and to arrange for timely healthcare intervention.
Further, I heard evidence that the newly implemented compliance audit plans for NEWS2 are not safe or robust because the audit is limited to monitoring the emergency review template on Systmone, which staff are routinely failing to utilise, instead preferring to add free text entries to the running record, which cannot be audited with ease. If the Trust is incapable of monitoring compliance with the initiative, there will be repeated missed opportunities to provide support and guidance to Directorates, wards or individual staff who are deviating from expected practice with regards to NEWS2.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of NEWS2 compliance auditing to reliably monitor adherence
Wider context from the report “1.(HEALTHCARE) Lack of safe system, supported by training, guidance, and compliance auditing, for the provision of physical healthcare assessment and monitoring by NEWS2 for acutely unwell patients in a secure setting.
The Jury found shortcomings in the healthcare afforded to Alex at HMP Nottingham in the form of "continuous failures to provide adequate healthcare, which probably more than minimally contributed to his death".
I heard evidence that staff were not consistently assessing acutely unwell patients using the NEWS2 system, despite the scoring system having been adopted across the NHS over the past decade and having been adopted by this Trust many years prior.
In 2017, when relaunching the NEWS system, the Royal College of Physicians noted, "Every so often, someone comes up with an idea that is so obvious, no one can understand why it wasn’t thought of before. I am proud that the RCP’s National Early Warning Score (NEWS) is one of those initiatives – not just a chart (or iPad) at the end of the bed to record the patient’s physical signs and symptoms, but the chart at the end of the bed – a single point of truth to unify recording of symptoms across the NHS, consolidate training for doctors and nurses in the recording of symptoms, and thereby improve patient safety. When the RCP launched the NEWS in 2012, we hoped to see the score adopted across the NHS. What has been more astonishing is the adoption of the score internationally, with requests to use NEWS coming from health services across the world from Europe to India and the USA, including the US Naval Air Forces!"
I heard evidence of an inconsistent application of NEWS2 by staff, an inconsistent awareness of NEWS2 across the staff body, and an absence of clear and robust training supported by guidance, ensuring staff were aware of the expectations of their employer with regards to the use of NEWS2 in monitoring acutely unwell patients.
Sadly, Alex’s is not an isolated case. I have been repeatedly assured at a senior level from Nottinghamshire Healthcare NHS Foundation Trust that they are seeking to embed NEWS2 across their Directorates, yet successive inquests have heard of patients failed by the lack of use of the system by the clinical staff responsible for their medical care. If this issue is not addressed across the Trust, with sufficient urgency, patients will continue to die in Trust settings due to a failure to recognise the deteriorating patient, and to arrange for timely healthcare intervention.
Further, I heard evidence that the newly implemented compliance audit plans for NEWS2 are not safe or robust because the audit is limited to monitoring the emergency review template on Systmone, which staff are routinely failing to utilise, instead preferring to add free text entries to the running record, which cannot be audited with ease . If the Trust is incapable of monitoring compliance with the initiative, there will be repeated missed opportunities to provide support and guidance to Directorates, wards or individual staff who are deviating from expected practice with regards to NEWS2.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Absence of an agreed joint care plan for acutely unwell prisoners remaining in prison
Wider context from the report “2. (HEALTHCARE AND HMP) The absence of a safe joint system of care (between discipline and healthcare staff) for supporting and managing acutely unwell patients who remain in the prison setting, rather than being transferred to a dedicated healthcare facility.
The very nature of incarceration curtails the prisoner’s free movement and ready access to healthcare. Instead, their incarceration places them wholly reliant on the communication between discipline staff on the wing, and healthcare staff available elsewhere within the setting, to obtain timely healthcare assessment and monitoring.
I heard evidence that Alex had been told to "press his cell bell" if he "felt worse". Both Alex and his cell mate did so repeatedly between 9 and 10 March 2020, with varying degrees of success regarding healthcare attendance at his cell.
Despite discipline and healthcare staff knowing that Alex was suffering with an acute illness, and in the knowledge that there was no plan for him to be transferred to a hospital, there was an absence of agreed joint plan between health and discipline staff as to how often Alex would be seen by each profession, what constitutes a deterioration for him, and what to do in the event of such a deterioration , to seek to detect and manage his risk of physical healthcare deterioration.
In contrast, in circumstances whereby a prisoner is thought to be at risk of self-harm or suicide, there is an agreed joint care planning system (ACCT Version 6) which sets out the clear expectations placed on each profession to seek to keep the prisoner safe (enshrined in Prison Service Instruction). There is no such equivalent system in operation nationally with regards to the risk of physical healthcare deterioration, but that does not absolve each service from ensuring acutely unwell patients are kept safe by way of robust joint local care planning.
If acutely unwell patients continue to be managed in the prison setting without an agreed joint plan of care between health and discipline staff , deaths will continue to occur in these circumstances.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Unclear cell-entry criteria for prison officers during life-threatening emergencies
Wider context from the report “3. (HM PRISON SERVICE) There continues to be a misunderstanding across discipline staff as to what constitutes a CODE BLUE/CODE RED situation, and in what circumstances a cell can be entered by a prison officer for the purpose of preserving life , despite this having been enshrined in Prison Service Instruction for many years.
I heard evidence from the PCO that he erroneously believed it was necessary for 3 discipline staff to be present before a cell door could be opened during night state even in circumstances where Alex was collapsed and unresponsive on the floor.
This is not the first-time issues of this nature have been identified at HMP Nottingham. Indeed, successive Prison and Probation Ombudsman reports have recommended that the Governor take action to address these issues since the cluster of deaths in 2017/2018, and while the prison has been subject to Urgent Notification procedures.
I heard evidence from a medical expert that post-cardiac arrest, every minute which elapses without appropriate CPR and defibrillator use reduces the patient’s chances of survival. Timely life support is critical, and staff must be clear on when to call a medical emergency code, and when to enter the cell, subject to their dynamic risk assessment.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding among discipline staff of medical emergency code criteria
Wider context from the report “3. (HM PRISON SERVICE) There continues to be a misunderstanding across discipline staff as to what constitutes a CODE BLUE/CODE RED situation , and in what circumstances a cell can be entered by a prison officer for the purpose of preserving life, despite this having been enshrined in Prison Service Instruction for many years.
I heard evidence from the PCO that he erroneously believed it was necessary for 3 discipline staff to be present before a cell door could be opened during night state even in circumstances where Alex was collapsed and unresponsive on the floor.
This is not the first-time issues of this nature have been identified at HMP Nottingham. Indeed, successive Prison and Probation Ombudsman reports have recommended that the Governor take action to address these issues since the cluster of deaths in 2017/2018, and while the prison has been subject to Urgent Notification procedures.
I heard evidence from a medical expert that post-cardiac arrest, every minute which elapses without appropriate CPR and defibrillator use reduces the patient’s chances of survival. Timely life support is critical, and staff must be clear on when to call a medical emergency code , and when to enter the cell, subject to their dynamic risk assessment.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly flag amendments to SystmOne medical records
Wider context from the report “4. (TPP-UK) Amendment of Medical Records without clear evidence of such amendment on the face of the SystmOne patient summary
The vast majority of primary care health services across the community and secure settings, such as prisons, utilise an electronic patient health record known as SystmOne.
I heard evidence that the system automatically records the date, time, and user, shown along the left-hand side of each entry in the printed patient summary, as below.
17 Apr 2019 08:11 Surgery: ████████ Health Professional Access Role)
I was assured by health staff that any retrospective entry or amendment to a previous entry in the patient record would be flagged by a new date and time stamp towards the right-hand side of the entry, as below.
24 Apr 2019 15:55 Surgery: ████████ Health Professional Access Role) Entered: 25 Apr 2019 11:55
However, in this case, I discovered from scrutinising an audit record, that an entry made in Alex’s patient record at 06.46 hours on 10 March 2020, had been amended by way of the deletion of some words, and the addition of others, at 09.30 hours on the same date, without any such time stamp being generated on the right-hand side of the entry . This made it look as if the entire text visible in the record would have been visible from around 06.46 hours that date.
The Head of Healthcare was unable to explain how the health professional who made the entry had been able to amend her previous entry, without it being obvious on the face of the record , after it became apparent Alex was critically unwell
This potentially raises serious safety issues about the integrity of the patient record, and at the very least, if the record is not as robust as first thought by its users, this ought to be made clear. I shall share this report with TPP-UK, the creators of SystmOne, to see if they can explain the safety features in place to ensure amended records are clearly marked as such , especially as in this case, the witness was not forthcoming about her amendment of Alex’s patient record. Accurate record keeping is integral to learning from incidents and seeking to prevent future deaths.
” 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 Provide a SystmOne audit trail showing amended content, the person making each amendment, and when it occurred.
Verbatim wording from the response “I am replying to section 5 (4) in your regulation 28 report. From the extract you included it appears that you have been presented with a printout taken from SystmOne. This is a routine function in the system that delivers a copy of the medical record into the Microsoft Word application. As such it is not to be used as a representation of the audit trail, and especially not for forensic investigation. The main reason for this was that the word document is editable – that is, entries can be reworked before saving and / or onward transmission and is therefore not to be considered secure. As is usual in IT systems the audit trail is held within SystmOne and is readily accessible to the user.” Source location Response from TPP
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 A Word printout is editable and cannot represent the SystmOne audit trail or establish that an entry was amended.
Verbatim wording from the response “I am replying to section 5 (4) in your regulation 28 report. From the extract you included it appears that you have been presented with a printout taken from SystmOne. This is a routine function in the system that delivers a copy of the medical record into the Microsoft Word application. As such it is not to be used as a representation of the audit trail, and especially not for forensic investigation. The main reason for this was that the word document is editable – that is, entries can be reworked before saving and / or onward transmission and is therefore not to be considered secure. As is usual in IT systems the audit trail is held within SystmOne and is readily accessible to the user.” Source location Response from TPP
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 SystmOne’s existing audit trail records amendments, users and times and is readily accessible, providing a complete and robust record.
Verbatim wording from the response “I am replying to section 5 (4) in your regulation 28 report. From the extract you included it appears that you have been presented with a printout taken from SystmOne. This is a routine function in the system that delivers a copy of the medical record into the Microsoft Word application. As such it is not to be used as a representation of the audit trail, and especially not for forensic investigation. The main reason for this was that the word document is editable – that is, entries can be reworked before saving and / or onward transmission and is therefore not to be considered secure. As is usual in IT systems the audit trail is held within SystmOne and is readily accessible to the user.” Source location Response from TPP
Open published response
2 Apr 2019 Tarek Mahmood CHOWDHURY · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Inadequate operation of SystmOne when new detainees arrive at IRCs View source Failure to share prisoner information between HMPPS, DEPMU and IRC staff View source Inadequate training of nurses on SystmOne and related access issues View source Failure of the process authorising IRC nurses to access former prisoners’ records 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.
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AI-generated summary
Tarek Mahmood CHOWDHURY · 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
Tarek Mahmood CHOWDHURY was beaten to death by another detainee while detained at Heathrow Immigration Removal Centre on 1 December 2016. The report identified concerns about information sharing between prisons, the Home Office and immigration removal centres, including the availability of intelligence and other records. It also identified concerns about access to and operation of SystmOne healthcare records during the initial screening of detainees transferred from prison.
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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Inadequate operation of SystmOne when new detainees arrive at IRCs
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs . There are concerns both about the technology itself of SystmOne ; about the process of authorising a nurse in an IRC to see records of a former prisoner; and about whether trainers are able adequately to train nurses in respect of these issues. These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to share prisoner information between HMPPS, DEPMU and IRC staff
Wider context from the report “(1) That there is a failure to share information about prisoners who are to become detainees, between HMPPS and the Home Office’s DEPMU, and between HMPPS and staff in IRCs . The rolling out of Mercury intelligence to DEPMU/IRCs will not solve this problem if other information (in particular NOMIS and OASYS) is still not available to DEPMU/IRCs . This concern is addressed both to the Ministry of Justice (HMPPS) and to the Home Office (DEPMU/IRCs).
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of nurses on SystmOne and related access issues
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs. There are concerns both about the technology itself of SystmOne; about the process of authorising a nurse in an IRC to see records of a former prisoner; and about whether trainers are able adequately to train nurses in respect of these issues . These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of the process authorising IRC nurses to access former prisoners’ records
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs. There are concerns both about the technology itself of SystmOne; about the process of authorising a nurse in an IRC to see records of a former prisoner ; and about whether trainers are able adequately to train nurses in respect of these issues. These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” Open source report
14 Jan 2014 Craig Adam White · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 4 Failure to provide continuing patient education about Infliximab treatment risks View source Delays in initiating treatment when tuberculous meningitis is suspected View source Lack of protocols for pre-Infliximab tuberculosis screening View source Lack of healthcare professional awareness of the increased tuberculosis risk inherent in Infliximab treatment 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
Craig Adam White · 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
Craig Adam White was a 21-year-old student who developed disseminated tuberculosis, including tuberculosis leptomeningitis, while receiving immunosuppressive treatment for Crohn’s disease. He had recurrent chest infections and later deteriorated with neurological illness before tuberculosis was confirmed. The principal concerns were tuberculosis screening before Infliximab treatment, healthcare professionals’ awareness of the associated risk, continuing patient education, and prompt treatment when tuberculous meningitis is suspected.
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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuing patient education about Infliximab treatment risks
Wider context from the report “3 The need for continuing patient education about the risks of Infliximab treatment
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Delays in initiating treatment when tuberculous meningitis is suspected
Wider context from the report “4 The need for prompt treatment to be initiated when tuberculous meningitis is suspected
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols for pre-Infliximab tuberculosis screening
Wider context from the report “1 Protocols for pre-Infliximab treatment screening for tuberculosis
” 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 The Phoenix Partnership (Leeds) Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare professional awareness of the increased tuberculosis risk inherent in Infliximab treatment
Wider context from the report “2 Awareness of Health Care Professionals, in particular prescribers of the increased risk of TB inherent Infliximab treatment
” 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