West Hertfordshire Teaching Hospitals NHS Trust

Health and care · NHS trust

Pin Request correction

First report 22 Jul 2014•Latest report 5 Feb 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
2

Naming this recipient

Published responses
50%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
3

Described in responses

Concerns and recipient responses

Statements from West Hertfordshire Teaching Hospitals NHS Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. North London

    AI-generated summary

    Mr Paz Ogbe-Millar · 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

    Mr Paz Ogbe-Millar died on 2 December 2021 after jumping in front of a high-speed train at Harrow and Wealdstone station, during a relapse in cannabis-induced psychosis. Concerns included his discharge from community mental health services, inadequate recording of police information about his self-harm risk, not allowing his mother to remain with him in the Emergency Department, referral-system problems, and insufficient observation arrangements for mental health patients awaiting assessment.

    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 West Hertfordshire Teaching Hospitals NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of consistent guidance on observation levels for mental health patients awaiting assessment in the Emergency Department

    Wider context from the report

    “a. Evidence was heard regarding the appropriate level of observation by Emergency Department staff of mental health patients waiting in the Emergency Department (operated by WHTHNT) to be seen by the Mental Health Liaison Team (operated by HPUNFT). There was confusion amongst the WHTHNT witnesses as to the appropriate level of observation. This was contributed to by a lack of clarity in WHTHNT’s (a) Standing Operating Procedure entitled: “Management of Mental Health Patients in the Emergency Department (ED) at Watford General Hospital (WGH): Standing Operating Procedure (SOP), Issue date August 2021”; when compared with (b) WHTHNT’s “Emergency Department Adult Mental Health Pro-forma” Version 3, Undated (“EDP”); b. The SOP states in a section titled “5. Procedure” (on page 4 of 16) “Patients at moderate or high risk of self-harm or of leaving before assessment and treatment should be observed closely whilst in the ED. There should be continuous observation, and this should be documented in the mental health presentation engagement record (Appendix 1); c. Whereas the EDP states at page 7 under the heading: “Summary of levels of risk and suggested action”, the following: “Low: No special observations required Medium: Consider 15-minute special observation”; d. Emphasis has been added above to paragraphs (b) and (c) in bold text; e. My concern is that the inconsistency between these two documents creates a risk that mental health patients admitted at medium risk of self-harm awaiting assessment for their mental health condition in the Emergency Department may not be subjected to an appropriate level of observation. ”
    Open source report

  2. Buckinghamshire

    AI-generated summary

    Molly Rae Keen · 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

    Molly Rae Keen was delivered by caesarean section on 10 June 2013 in a very poor condition, and resuscitation was stopped at 11.54 hours. The report raised concerns about inconsistent use and recording of fetal growth charts, the failure to refer for further opinion or a possible scan despite indications of below-normal growth, and a continuing lack of clarity in joint care arrangements.

    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 West Hertfordshire Teaching Hospitals NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clarity in the delivery of joint antenatal care

    Wider context from the report

    “1a) Buckinghamshire Healthcare NHS Trust (Bucks) employ a customised growth chart as part of their ante natal care. Where ante natal care is provided in West Hertfordshire Hospitals NHS Trust (West Herts) but the birth is intended to happen at Stoke Mandeville Hospital then Bucks supply a growth chart to be kept in the mothers file and utilised. 1b) West Herts do not use customised growth charts for their own deliveries. 1c) An expert witness in midwifery opined that where a chart is supplied, it should be used. 1d) Discussions between Bucks and West Herts to improve this aspect of joint care are currently in abeyance. There is a continuing absence of clarity as to how such joint care should be delivered. ”
    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 West Hertfordshire Teaching Hospitals NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to use customised growth charts when supplied or for West Herts deliveries

    Wider context from the report

    “1a) Buckinghamshire Healthcare NHS Trust (Bucks) employ a customised growth chart as part of their ante natal care. Where ante natal care is provided in West Hertfordshire Hospitals NHS Trust (West Herts) but the birth is intended to happen at Stoke Mandeville Hospital then Bucks supply a growth chart to be kept in the mothers file and utilised. 1b) West Herts do not use customised growth charts for their own deliveries. 1c) An expert witness in midwifery opined that where a chart is supplied, it should be used. 1d) Discussions between Bucks and West Herts to improve this aspect of joint care are currently in abeyance. There is a continuing absence of clarity as to how such joint care should be delivered. ”
    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 West Hertfordshire Teaching Hospitals NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to refer cases for further assessment when fetal growth is below normal expectations

    Wider context from the report

    “2) Midwives within West Herts estimate fetal growth by measuring fundal height. However:- a) In the immediate case, measurements were variously part recorded on the growth chart, or written on the file, or not recorded at all. As a consequence, an overall assessment of fetal growth is obscured. b) The evidence disclosed that although there was (nevertheless), clear indication that the growth of the baby was below normal expectations, no attempt was made to refer the case for further opinion, and a possible scan. ”
    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 West Hertfordshire Teaching Hospitals NHS Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Incomplete and inconsistent recording of fundal-height measurements

    Wider context from the report

    “2) Midwives within West Herts estimate fetal growth by measuring fundal height. However:- a) In the immediate case, measurements were variously part recorded on the growth chart, or written on the file, or not recorded at all. As a consequence, an overall assessment of fetal growth is obscured. b) The evidence disclosed that although there was (nevertheless), clear indication that the growth of the baby was below normal expectations, no attempt was made to refer the case for further opinion, and a possible scan. ”
    Open source report
Back to top

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

Data last updated 7 September 2026