14 Jun 2022 Keith Andrew NOTTLE · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Failure to ensure specialist mental health assessment of patients triaged by telephone workers View source Failure of the multi-disciplinary team to respond appropriately to repeated re-referrals View source Lack of clarity in multi-disciplinary team decision-making about discharge View source Lack of care co-ordination for patients receiving assistance from multiple agencies and persons View source See 1 more concern
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Review and refresh helpline workers’ roles, referral escalation, training, supervision, monitoring and audit arrangements.
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Action
Agree a competency framework covering staff confidence in handling calls and escalating risk.
View source
Action
Agree a standard operating procedure governing helpline referrals to the Crisis Team.
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Action
Introduce additional monitoring and audits to check compliance with the referral procedure and address variance promptly.
View source
Action
Ensure helpline workers and their team leader understand the referral standard operating procedure.
View source See 2 more actions
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AI-generated summary
Keith Andrew NOTTLE · 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
Keith Andrew Nottle died on 5 July 2021 after taking an overdose of two prescribed medications, which the inquest concluded was an accident. Concerns included telephone triage practices that could bypass specialist mental health assessment, the apparent lack of care coordination, and unclear decision-making around his discharge and repeated re-referrals to mental health services.
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 Turning Point; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure specialist mental health assessment of patients triaged by telephone workers
Wider context from the report “Evidence was heard regarding the operation of a triage for patients who may be experiencing a mental health crisis. A practice had developed of bypassing specialist mental health assessment by means of telephone workers making their own judgments about the level of risk a person presents to themselves and others, and a judgment about whether or not they require urgent mental health assessment and / or treatment, based on a very limited criteria. This had the result of only a very small proportion of potentially unwell patients being considered by a person with qualifications to assess and treat mental health. This was a culture and practice which stood in conflict with the procedure the Trust had in writing for the role of the telephone workers.
” 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 Turning Point; that does not assign responsibility.
PFD Monitor interpretation Failure of the multi-disciplinary team to respond appropriately to repeated re-referrals
Wider context from the report “Lastly, I was concerned that there was evidence of a lack of clarity of thinking within the multi-disciplinary team in relation to the decision to discharge Mr Nottle and the apparent recalcitrance of the multi-disciplinary team in relation to repeated re-referrals into the service . This may be linked with the lack of care co-ordination or may be a cultural or practice issue within the operation of the multi-disciplinary team.
” 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 Turning Point; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in multi-disciplinary team decision-making about discharge
Wider context from the report “Lastly, I was concerned that there was evidence of a lack of clarity of thinking within the multi-disciplinary team in relation to the decision to discharge Mr Nottle and the apparent recalcitrance of the multi-disciplinary team in relation to repeated re-referrals into the service. This may be linked with the lack of care co-ordination or may be a cultural or practice issue within the operation of the multi-disciplinary team.
” 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 Turning Point; that does not assign responsibility.
PFD Monitor interpretation Lack of care co-ordination for patients receiving assistance from multiple agencies and persons
Wider context from the report “I was also concerned regarding the apparent lack of involvement of a care co-ordinator at the Trust , given that a variety of agencies and persons were involved in seeking to assist and treat Mr Nottle.
” 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 Review and refresh helpline workers’ roles, referral escalation, training, supervision, monitoring and audit arrangements.
Verbatim wording from the response “We have reviewed and refreshed the key factors in the role of the helpline (telephone) workers with colleagues in Nottinghamshire Healthcare Trust, including when and how referrals are escalated to the Crisis Team, training, supervision, monitoring and audit.” Source location Response from Turning Point
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 Agree a competency framework covering staff confidence in handling calls and escalating risk.
Verbatim wording from the response “We have also agreed a competency framework to provide assurance that our staff are confident in their ability to handle calls and the escalation process regarding risk, amongst other areas.” Source location Response from Turning Point
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 Agree a standard operating procedure governing helpline referrals to the Crisis Team.
Verbatim wording from the response “We have met with our colleagues from Nottinghamshire Healthcare Trust on a number of occasions and agreed a Standard Operating Procedure (SOP) for the flow of referrals from the helpline workers to the Crisis Team. This SOP is in line with the service specification and national guidance regarding access to mental health services.” Source location Response from Turning Point
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 Introduce additional monitoring and audits to check compliance with the referral procedure and address variance promptly.
Verbatim wording from the response “We have introduced additional monitoring and audits to ensure that all helpline workers are following the SOP and any variance is addressed in a timely way.” Source location Response from Turning Point
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 Ensure helpline workers and their team leader understand the referral standard operating procedure.
Verbatim wording from the response “We have met with the team of helpline workers and their team leader and ensured that they are familiar with the detail of the SOP.” Source location Response from Turning Point
Open published response
Concerns raised 2 Failure to consider a lower methadone starting dose for patients with liver disease View source Failure to obtain and verify relevant information about liver disease before prescribing View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Provide every organisational team with an NHS.net email address to enable secure information sharing with NHS bodies and employees.
View source
Action
Carry out a national audit of medical information available to opioid-substitute-treatment prescribers and documented interim considerations or actions.
View source
Action
Produce and distribute an educational support pack on hepatic dysfunction and methadone metabolism to clinically involved substance-misuse staff.
View source
Action
Publish a clinical brief reminding all clinical staff about safe opioid-substitute-treatment prescribing.
View source
Action
Develop and roll out a multiple-choice assessment of the educational support pack, with learning monitored through clinical supervision.
View source
Action
Host a clinical session on safe opioid-substitute-treatment prescribing for representatives from every service, supporting subsequent local learning cascades.
View source See 3 more actions
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AI-generated summary
Natalie Jane Edgington · 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
Natalie Jane Edgington, aged 28, died at her mother’s address on 24 February 2020. She died from the effects of an accumulated dose of methadone, which she was unable to properly eliminate because of impaired liver function. Concerns included prescribing methadone without sufficient information about her liver disease or an up-to-date liver function test, and the absence of evidence that a lower starting dose was considered.
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 Turning Point; that does not assign responsibility.
PFD Monitor interpretation Failure to consider a lower methadone starting dose for patients with liver disease
Wider context from the report “2. The BNF recommends that consideration should be given to starting patients with a history of liver disease on a lower dose of methadone than the standard starting dose of 30mls. There was no evidence to suggest that any consideration was given to starting the Deceased on a lower dose.
” 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 Turning Point; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and verify relevant information about liver disease before prescribing
Wider context from the report “1. That prescribers should have full information about the nature and extent of a service user’s liver disease in order to ensure that prescribing is within safe limits. The prescription to the Deceased was issued without relevant medical information that could have been obtained from the GP and/or an up to date liver function test. There is a risk associated with reliance on a service users self-reporting of his/her own medical history particularly against a background of non-attendance at medical appointments.
” 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 every organisational team with an NHS.net email address to enable secure information sharing with NHS bodies and employees.
Verbatim wording from the response “6) We have made arrangements to provide every team within the organisation with an NHS.net email address. The work was completed on 14th October 2020. This ensures that data can be shared securely and efficiently between Turning Point and NHS bodies/employees (such as a GP surgery).” Source location Response from Turning Point
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 Carry out a national audit of medical information available to opioid-substitute-treatment prescribers and documented interim considerations or actions.
Verbatim wording from the response “5) Turning Point will carry out a national audit across all substance misuse services in relation to the medical information available to an OST prescriber at the point of prescription and the documentation of considerations/actions taken pending receipt of background information. This audit will take place in June 2021 to assess the impact of the learning as set out above.” Source location Response from Turning Point
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 Produce and distribute an educational support pack on hepatic dysfunction and methadone metabolism to clinically involved substance-misuse staff.
Verbatim wording from the response “1) We have produced an educational support pack on “The effects of hepatic dysfunction on the metabolism of methadone”. I attach a copy of this document for your information. This was distributed on 26 January 2021 to all staff within the organisation who have a clinical role in relation to the treatment of substance misuse. Whilst the document as a whole is relevant to the concerns raised, I highlight particularly the recommendations for staff at page 6 of the document which include the following:” Source location Response from Turning Point
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 Publish a clinical brief reminding all clinical staff about safe opioid-substitute-treatment prescribing.
Verbatim wording from the response “4) The Turning Point Public Health and Substance Misuse Senior Clinical Governance Group published within their January 2021 monthly clinical brief a reminder to all clinical staff on prescribing OST safely. I attach a copy of this document for your information. You will see that the key areas included in this brief are relevant to your concerns reflect those as set out in point 3 above.” Source location Response from Turning Point
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 Develop and roll out a multiple-choice assessment of the educational support pack, with learning monitored through clinical supervision.
Verbatim wording from the response “2) We are producing a Multiple Choice Question (MCQ) assessment of the educational support pack referred to in point 1. This assessment will be rolled out at the end of March 2021 and will be monitored through the clinical supervision structure to ensure that the learning has been cascaded and embedded through all relevant sections of the organisation.” Source location Response from Turning Point
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 Host a clinical session on safe opioid-substitute-treatment prescribing for representatives from every service, supporting subsequent local learning cascades.
Verbatim wording from the response “3) ████████ (Clinical Director) and ████████ (Chief Pharmacist) hosted a clinical session on prescribing Opioid Substitute Treatment (OST) (which includes methadone) safely on Thursday 14 January 2021. In attendance at this session was at least one clinician and one operational representative from every service under the Turning Point umbrella with the aim that that clinician then cascaded the learning within their own service (please see point 4 for further support for this process). Key points from this session included:” Source location Response from Turning Point
Open published response
10 Jun 2019 Beverley Shaw · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Failure to communicate clinically significant butane gas use and consumption amount to the GP practice View source Failure to transfer the full medical records and past medical history to the new substance misuse service View source Failure to conduct a full review of all prescribed medications View source Failure to respond to and action clinical information requests from the substance misuse service View source See 1 more concern
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Change prescriber templates used to review clients across community substance misuse services.
View source
Action
Complete a wide-ranging review of GP communication across all community substance misuse services.
View source
Action
Change the frequency of communication with GPs across community substance misuse services.
View source
Action
Review and improve follow-up systems for requests to GPs for information.
View source
Action
Improve processes for transferring client data at the beginning and end of contracts.
View source
Action
Improve recording of GP communications in the electronic client records system.
View source See 3 more actions
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AI-generated summary
Beverley Shaw · 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
Beverley Shaw was found deceased in her bed at home in Oldham in the early hours of 11 December 2018. The inquest heard that she had multiple prescribed medicines, was receiving methadone, and was using cocaine and butane gas. Concerns included inadequate communication between the substance misuse service and GP practice about her butane gas use, lack of a full medication review, and incomplete transfer of medical records.
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 Turning Point; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate clinically significant butane gas use and consumption amount to the GP practice
Wider context from the report “○ There was a lack of communication between Turning Point and the GP practice specifically in respect of Ms Shaw’s use of butane gas. There was no information contained in the evidence before the Court to indicate her GP was aware of the use of butane gas , which was significant (ie 5 cans a day). This was described in evidence by Turning Point as her most significant addiction which was not amenable to treatment with medication. There was one 4 page letter dated the 15th May 2018 from Turning Point to the GP practice, in the summary section this simply recorded, “Uses butane gas daily.” In the section headed “Current Reported Substance Use” there is no mention of butane gas. The remainder of this letter deals with other matters. No information was shared with the GP with regards to the amount of gas being used by Ms Shaw.
” 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 Turning Point; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer the full medical records and past medical history to the new substance misuse service
Wider context from the report “○ The Court heard evidence that following the transition from another provider to Turning Point a decision was taken that all medical records relating to users of the substance misuse service do not need to be carried over to Turning Point . Unlike other medical records ie GP records which go with the patient when they move surgery the new substance misuse service only receives the last 6 months records hence they do not have the full past medical history available.
” 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 Turning Point; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a full review of all prescribed medications
Wider context from the report “○ A medication review took place in the GP practice in August 208, this only documented a review of her olanzapine medication and the fact that she was in receipt of methadone and using cocaine. There is no evidence that there was a full review of all the medications prescribed to Ms Shaw. When questioned it was accepted in Court it was unclear as to why she was still being prescribed a number of medications.
” 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 Turning Point; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to and action clinical information requests from the substance misuse service
Wider context from the report “○ There is no record of a response from the GP practice to Turning Point following their letter dated the 15th May 2018. This had a number of requests for actions by the GP including the sharing of any blood results (LFT, FC and U&E), together with information confirming whether there was any blood disorders of drugs which may interact with methadone. There was no evidence that this information was shared or actioned.
” 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 Change prescriber templates used to review clients across community substance misuse services.
Verbatim wording from the response “This review has highlighted the key processes that we needed to change in order to improve effective communication and reduce the risk of future recurrence. Those processes are the template used by prescribers to review clients, the frequency of communication with GPs, the way that communication is recorded on our electronic client records system and the processes for audit of the frequency of that communication.” Source location 2019-0191-Response-by-Turning-Point
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 Complete a wide-ranging review of GP communication across all community substance misuse services.
Verbatim wording from the response “Whilst we recognise that the clinician had written to the GP, we accept that there is more that we could do to improve this communication, not only in this tragic case but also more broadly across our substance misuse services. Therefore, we have undertaken a wide ranging review of GP communication across all our community substance misuse services, not just in Rochdale and Oldham. That review has been led by our Senior Management Team, including our senior clinical team, and our Risk and Assurance department.” Source location 2019-0191-Response-by-Turning-Point
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 Change the frequency of communication with GPs across community substance misuse services.
Verbatim wording from the response “This review has highlighted the key processes that we needed to change in order to improve effective communication and reduce the risk of future recurrence. Those processes are the template used by prescribers to review clients, the frequency of communication with GPs, the way that communication is recorded on our electronic client records system and the processes for audit of the frequency of that communication.” Source location 2019-0191-Response-by-Turning-Point
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 Review and improve follow-up systems for requests to GPs for information.
Verbatim wording from the response “We also reviewed our systems for following up requests to GPs for information and the way in which we transfer client data at the beginning and at the end of contracts.” Source location 2019-0191-Response-by-Turning-Point
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 Improve processes for transferring client data at the beginning and end of contracts.
Verbatim wording from the response “We also reviewed our systems for following up requests to GPs for information and the way in which we transfer client data at the beginning and at the end of contracts.” Source location 2019-0191-Response-by-Turning-Point
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 Improve recording of GP communications in the electronic client records system.
Verbatim wording from the response “This review has highlighted the key processes that we needed to change in order to improve effective communication and reduce the risk of future recurrence. Those processes are the template used by prescribers to review clients, the frequency of communication with GPs, the way that communication is recorded on our electronic client records system and the processes for audit of the frequency of that communication.” Source location 2019-0191-Response-by-Turning-Point
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations