20 Aug 2025 Mary Anne FITZPATRICK · Prevention of Future Deaths report Inner North London
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Concerns raised 3 Failure to undertake serious reflection on poor district nursing outcomes View source Insufficient staffing for safe transfer of elderly patients View source Failure to provide district nursing wound care at appropriate frequency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mary Anne FITZPATRICK · 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
Mary Anne Fitzpatrick was discharged from hospital on 29 January 2025 and received district nursing care. A sacral pressure sore progressed from category 2 to category 4, leading to readmission on 27 February, deconditioning and her death. Concerns included the frequency and adequacy of wound dressing visits, the development and treatment of the pressure sore, and insufficient reflection by the district nursing team after her death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake serious reflection on poor district nursing outcomes
Wider context from the report “3. When I took evidence from the deputy manager of the Islington Central district nursing team, I was very forcibly struck by the lack of reflection undertaken since Mrs Fitzpatrick’s death, about the district nursing care , even when preparing to give evidence at inquest.
The deputy manager was poorly prepared for inquest, appeared to have an inadequate understanding of what was required of her giving evidence, had not acquainted herself with some basic elements of the medical records and, whilst in the witness box, changed her mind about what home visits had been undertaken depending upon who asked her the question.
She steadfastly refused to acknowledge gaps in care despite glaring evidence to the contrary, and when this was brought to her attention she simply stopped answering.
It is difficult to see how a trust can learn and improve care if there is no serious consideration of why there was a poor outcome.
Even the letter of apology sent to Mrs Fitzpatrick’s family was offered to her daughter in an offhand way during a very short telephone call. When giving evidence, the deputy manager seemed to be in difficulty understanding what an apology is, naming this a letter of apology but in essence describing a letter of sympathy, emphasising that it was not an admission that the trust had done anything wrong. I still do not have a proper understanding of what such a letter was meant to achieve. Much more importantly, it seemed to me that Mrs Fitzpatrick’s family do not have a proper understanding of what this letter was meant to achieve. They did not seem comforted by it.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing for safe transfer of elderly patients
Wider context from the report “1. It is well recognised that the admission of an elderly person to hospital can be risky and should only be undertaken if really necessary. These days, a long wait on a hospital trolley is predictable. Even without that, the elderly are known often to decondition quickly.
At inquest I accepted the evidence of Mrs Fitzpatrick’s family that the reality of her admission to the Whittington on 23 January 2025 was that it was undertaken because there was only one nurse attending her on that day and this nurse felt she could not transfer this small, elderly lady alone with the aids that were 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide district nursing wound care at appropriate frequency
Wider context from the report “2. The district nurses did not visit to dress the sacral wound with appropriate frequency. Sometimes they attended as planned, but sometimes they did not attend and sometimes they attended but did not change the sacral dressing . It remains unclear to me why that was so. The only explanation I was given was that they were probably “thin on the ground”.
” 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 Include tissue-viability referrals, recommendation adherence and pressure-ulcer improvement-plan progress in quarterly audits and divisional quality review.
Verbatim wording from the response “• Timely referral to Tissue Viability Nurse (TVN), adherence with TVN recommendations, and progression of pressure ulcer management improvement plan are to be built into new quarterly audit cycle, and reviewed at divisional quality meeting.” Source location Response from Whittington Health NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share incidents, feedback, inquest outcomes and Prevention of Future Deaths notices with staff, including through community-services-wide cascades.
Verbatim wording from the response “Learning from Death: incidents and feedback, inquest outcomes and PFD notices will continue to be shared with staff at meetings. In addition, they will also be cascaded to all staff working in community services.” Source location Response from Whittington Health NHS Trust
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 Trial visit-allocation software in the urgent-response team to assess whether it can reduce travel time and increase visit time.
Verbatim wording from the response “• A trial of visit allocation software (Docabode) is in progress in the Urgent response team and is intended to minimise travel time and maximise time for visits. If successful it will be trialled in District Nursing” Source location Response from Whittington Health NHS Trust
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 Individualise daily district-nursing visit allocations for patients’ pressure-ulcer management needs, with monthly service-lead oversight.
Verbatim wording from the response “• Ensure daily visits allocations are individualised to meet the patients’ Pressure Ulcer (PU) management need by the duty manager, with monthly oversight from Service Lead.” Source location Response from Whittington Health NHS Trust
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 procedures to formally review deaths under community-services care for learning.
Verbatim wording from the response “Mortality review process: Current mortality review processes are largely designed to cover inpatients. New procedures are being devised to ensure all patient deaths under our care in the community services we run are formally reviewed for learning.” Source location Response from Whittington Health NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share pressure-ulcer incident learning through weekly divisional shared-learning meetings.
Verbatim wording from the response “• Shared learning from PU incidents will be ensured via weekly divisional pressure ulcer shared learning meetings.” Source location Response from Whittington Health NHS Trust
Open published response
20 Jun 2025 Finlay Joshua ROBERTS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Lack of paediatric nursing observations View source Failure of medical staff to recognise absent nursing observations View source Failure to complete final nursing observations before discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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. 13
Action
Require review of vital signs before paediatric discharge through the ED discharge checklist and audit its use regularly.
Stated completedThe respondent said that this action was complete when they made their response on 14 July 2025. View source
Action
Disseminate the ED paediatric discharge checklist at emergency, surgical and paediatric inductions and thereafter at future medical inductions.
Stated plannedThe respondent said that this action was planned when they made their response on 14 July 2025. View source
Action
Provide vital-signs, escalation, local-induction and policy training to nurses and other clinical staff, including triage competency training.
Stated completedThe respondent said that this action was complete when they made their response on 14 July 2025. View source
Action
Require complete triage vital-sign sets for children with medical complaints and escalate abnormal or repeat observations using PEWS and national guidance.
Stated completedThe respondent said that this action was complete when they made their response on 14 July 2025. View source
Action
Allocate paediatric emergency cubicles and patient cohorts to designated nurses to establish responsibility and continuity of care.
Stated completedThe respondent said that this action was complete when they made their response on 14 July 2025. View source
Action
Continue staff training and induction on complete observations and escalation, including the content in paediatric emergency simulation training.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025. View source
Action
Review paediatric emergency staffing against safer-nursing-care data and professional judgement, resulting in additional nursing staff, with ongoing safety-level monitoring.
Stated completedThe respondent said that this action was complete when they made their response on 14 July 2025. View source
Action
Monitor observation-compliance safety through clinical governance committees and report to the Patient Safety Group and Trust Board.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025. View source
Action
Deploy electronic vital-sign devices, upgrade the nurse-in-charge workstation and update the paediatric emergency digital medical record and assessment proforma.
Stated completedThe respondent said that this action was complete when they made their response on 14 July 2025. View source
Action
Embed PEWS and observation escalation in multidisciplinary simulation training for emergency and paediatric teams.
Stated completedThe respondent said that this action was complete when they made their response on 14 July 2025. View source
Action
Conduct monthly, random manual and quarterly governance audits of vital-sign observation compliance, providing feedback and identifying training needs.
Stated completedThe respondent said that this action was complete when they made their response on 14 July 2025. View source
Action
Require paediatric clerking documentation to specify the frequency of observations.
Stated completedThe respondent said that this action was complete when they made their response on 14 July 2025. View source
Action
Conduct quarterly audits of paediatric discharge-checklist compliance and present results to the divisional quality meeting.
Stated plannedThe respondent said that this action was planned when they made their response on 14 July 2025. View source See 10 more actions
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AI-generated summary
Finlay Joshua ROBERTS · 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’s parents took him to Whittington Hospital the night before he died, during an extremely busy and understaffed night in the paediatric emergency department. The report describes failures to conduct serial nursing observations, complete appropriate tests, and obtain specialist advice before Finlay was discharged home. The principal concerns were that missing nursing observations may be a wider issue and that medical staff failed to recognise that the observations had not been carried out.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of paediatric nursing observations
Wider context from the report “The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff.
However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks.
I remain concerned on two counts:
1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.
2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of medical staff to recognise absent nursing observations
Wider context from the report “The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff.
However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks.
I remain concerned on two counts:
1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.
2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete final nursing observations before discharge
Wider context from the report “The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff.
However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks.
I remain concerned on two counts:
1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual.
2. The medical staff at the Whittington did not recognise the lack of nursing observations.
• Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent.
• The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged.
” 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 Require review of vital signs before paediatric discharge through the ED discharge checklist and audit its use regularly.
Verbatim wording from the response “◦ The ED paediatric discharge checklist now requires that there is a review of patient’s vital signs prior to discharge. This has been implemented since Finlay’s death and its use will be audited regularly.” Source location 2025-0316 Response from Whittington Health NHS Trust
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 Disseminate the ED paediatric discharge checklist at emergency, surgical and paediatric inductions and thereafter at future medical inductions.
Verbatim wording from the response “◦ The discharge checklist will be disseminated at ED and surgical induction in August and paediatric induction in September and at all future medical inductions thereafter.” Source location 2025-0316 Response from Whittington Health NHS Trust
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 Provide vital-signs, escalation, local-induction and policy training to nurses and other clinical staff, including triage competency training.
Verbatim wording from the response “• Training & Induction Enhancements:
◦ All new nurses now receive training on vital signs monitoring and escalation during induction and in-house triage training. This ensures that all new starters have a foundational understanding of the importance of recording and escalating abnormal observations from the outset. All clinical staff are also required to familiarise themselves with the department’s common presentation policies during their induction.” Source location 2025-0316 Response from Whittington Health NHS Trust
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 Require complete triage vital-sign sets for children with medical complaints and escalate abnormal or repeat observations using PEWS and national guidance.
Verbatim wording from the response “◦ At triage a complete set of vital signs appropriate to their clinical presentation is required for every child presenting to the department with a medical complaint. This standard has been reinforced through the Emergency Department Triage Training Study Day, which all triage nurses attend. These triage observations will be as recommended by the Royal College of Emergency Medicine (RCEM)” Source location 2025-0316 Response from Whittington Health NHS Trust
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 Allocate paediatric emergency cubicles and patient cohorts to designated nurses to establish responsibility and continuity of care.
Verbatim wording from the response “◦ We have introduced the allocation of cubicles where nurses are assigned responsibility for specific cubicles and key assessments i.e. Triage and patient cohorts to ensure ownership and continuity of care.” Source location 2025-0316 Response from Whittington Health NHS Trust
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 Continue staff training and induction on complete observations and escalation, including the content in paediatric emergency simulation training.
Verbatim wording from the response “• Ongoing training and induction for all staff in regard to the importance of complete observations and their escalation. This training will also be part of all simulation training in PED” Source location 2025-0316 Response from Whittington Health NHS Trust
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 paediatric emergency staffing against safer-nursing-care data and professional judgement, resulting in additional nursing staff, with ongoing safety-level monitoring.
Verbatim wording from the response “◦ Staffing levels in the Paediatric Emergency department have been reviewed and aligned with SNCT (safer nursing care tool data), and professional judgement based on staff feedback. This review resulted in additional nursing staff. The staffing levels will continue to be reviewed and reported to the Board on a six monthly basis.” Source location 2025-0316 Response from Whittington Health NHS Trust
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 Monitor observation-compliance safety through clinical governance committees and report to the Patient Safety Group and Trust Board.
Verbatim wording from the response “• Ongoing monitoring of compliance by the senior nursing and medical team with oversight from the paediatric and emergency department clinical governance committees reporting into the Patient Safety Group on a 3 monthly basis. Patient Safety Group reports to Trust Board via the Quality Governance and Quality Assurance Committees.” Source location 2025-0316 Response from Whittington Health NHS Trust
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 Deploy electronic vital-sign devices, upgrade the nurse-in-charge workstation and update the paediatric emergency digital medical record and assessment proforma.
Verbatim wording from the response “• Electronic Monitoring Enhancements:
◦ Four additional electronic devices have been deployed in the department to facilitate real-time recording and review of vital signs. Each Nursing staff member has access to an electronic device for inputting Vital signs.” Source location 2025-0316 Response from Whittington Health NHS Trust
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 Embed PEWS and observation escalation in multidisciplinary simulation training for emergency and paediatric teams.
Verbatim wording from the response “• Simulation Training with PEWS:
◦ Paediatric Early Warning Scores (PEWS) have been embedded into multidisciplinary simulation training. These simulations take place on alternative Thursdays, including the children’s and young people department which allows collaborative learning for acute Paediatrics.” Source location 2025-0316 Response from Whittington Health NHS Trust
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 Conduct monthly, random manual and quarterly governance audits of vital-sign observation compliance, providing feedback and identifying training needs.
Verbatim wording from the response “• Monthly and Manual Audits:
◦ Monthly audits of compliance with vital sign observations have been instituted with the support of the Information Requests Team, with outcomes reviewed by the paediatric emergency department senior team. These will be used to identify ongoing training needs and support continuous improvement with feedback to the team.” Source location 2025-0316 Response from Whittington Health NHS Trust
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 Require paediatric clerking documentation to specify the frequency of observations.
Verbatim wording from the response “We acknowledge that staff failed to identify that vital observations were incomplete and not repeated at the time of Finlay’s discharge. In response:” Source location 2025-0316 Response from Whittington Health NHS Trust
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 Conduct quarterly audits of paediatric discharge-checklist compliance and present results to the divisional quality meeting.
Verbatim wording from the response “◦ Audits will be conducted and will be presented at the division’s quality meeting on a quarterly basis.” Source location 2025-0316 Response from Whittington Health NHS Trust
Open published response
28 Mar 2025 Derrick Frederick Tully · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 7 Failure to record significant post-fall injuries in care notes View source Failure to assess reablement suitability in light of cognitive impairment and unreliable self-reporting View source Failure to provide emergency access to the flat for carers and emergency services View source Failure to account for cognitive, mental health and home-safety barriers when assessing engagement View source Failure to award medical points despite evidence of unsuitable accommodation and health needs View source Failure to escalate significant post-fall injuries for medical review View source Inaccessible temporary accommodation for wheeled-walker use View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Derrick Frederick Tully · 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
Derrick Frederick Tully was found deceased at home on 20 March 2024 after suffering a massive traumatic subdural haemorrhage, following months of falls and declining health. Concerns included unsuitable temporary accommodation, the absence of a key safe despite repeated concerns, an inappropriate reablement care package, failures to record or escalate injuries after a fall, and the discharge of Derrick from a community team without adequately factoring in his cognitive, mental health and safety difficulties.
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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record significant post-fall injuries in care notes
Wider context from the report “On 20 February Derrick suffered a fall. Severe bruising and swelling developed on his face over the following days but this was not recorded in his care notes by his carers and not escalated until his daughter raised concerns on 24 February. “No concerns” was written in Derrick’s care record and no consideration given to whether he needed to be reviewed by a doctor.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess reablement suitability in light of cognitive impairment and unreliable self-reporting
Wider context from the report “On discharge from hospital on 3 February 2024 following a fall, Derrick was provided with a good package of care. On 23 February this changed to a reablement package of care. Derrick was not suitable for reablement because of his declining cognition and progressive dementia . The occupational therapist raised concerns that he was not suitable for reablement for these reasons and because there were no rehabilitation goals. There was an over-reliance on Derrick’s self-reporting which was inaccurate given his memory problems , and a focus on him doing more for himself. He began losing weight because he was not eating, and he was not able to cope with self-care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide emergency access to the flat for carers and emergency services
Wider context from the report “Derrick required carers twice a day. He was also given a pendant alarm for emergencies. However, no key safe was installed meaning that even in an emergency, neither carers nor emergency services could gain entry to his flat . This was raised repeatedly by his family, carers and other professionals.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for cognitive, mental health and home-safety barriers when assessing engagement
Wider context from the report “Following MDT meetings due to concerns over Derrick’s increasing deterioration and ability to cope with his own care needs, the Integrated Community Aging Team reviewed him on 6 March. They discharged him from the service on 12 March because he did not want to engage with their home assessment of him . Derrick was suffering from cognitive impairment as a result of previous strokes and newly diagnosed dementia. He also had a mental health history and was paranoid. This was compounded by problems he’d experienced with neighbours and cuckooing concerns meaning that at times, he didn’t feel safe at home. It does not appear that these were factored into his inability to engage with the 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to award medical points despite evidence of unsuitable accommodation and health needs
Wider context from the report “Derrick was provided with a wheeled walker to reduce the risk of falls. Although Derrick’s temporary accommodation was ground floor, there were steps down from the building to street level and he was thus unable to manoeuvre the walker out of the property. Despite a social care letter of support, outlining concerns that his current accommodation was unsuitable and detailing Derrick’s health problems, the housing options team did not award him any medical points .
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate significant post-fall injuries for medical review
Wider context from the report “On 20 February Derrick suffered a fall. Severe bruising and swelling developed on his face over the following days but this was not recorded in his care notes by his carers and not escalated until his daughter raised concerns on 24 February . “No concerns” was written in Derrick’s care record and no consideration given to whether he needed to be reviewed by a doctor .
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccessible temporary accommodation for wheeled-walker use
Wider context from the report “Derrick was provided with a wheeled walker to reduce the risk of falls. Although Derrick’s temporary accommodation was ground floor, there were steps down from the building to street level and he was thus unable to manoeuvre the walker out of the property . Despite a social care letter of support, outlining concerns that his current accommodation was unsuitable and detailing Derrick’s health problems, the housing options team did not award him any medical points.
” 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 Conduct an independent structured judgement review and discuss its findings at ICAT governance and safeguarding meetings.
Verbatim wording from the response “The Lead Consultant for the Integrated Community Aging team (ICAT) has confirmed that families are usually involved as much as possible in assessments with the consent of patients in ICAT service. Where a patient does not have capacity to decline speaking with their next of kin, attempts are made to do so in their best interests. It is unclear why this did not happen in this case, and this will be explored in detail following an independent structured judgement review at the next ICAT governance meeting on May 21st, 2025. The minutes for those unable to attend will be disseminated by email and one to one discussions. This case will also be discussed at weekly Safeguarding drop ins on 6th May 2025.” Source location Response from Whittington Health NHS Trust
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 Conduct mental-capacity assessments for patients who do not engage with services and involve families where appropriate.
Verbatim wording from the response “• Mental capacity assessment will be conducted for all patients when they are not engaging with services as well as family involvement where appropriate.” Source location Response from Whittington Health NHS Trust
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 Add assessment-proforma requirements to consult patients’ families where appropriate and document mental-capacity decisions when patients do not consent.
Verbatim wording from the response “In terms of how such incidents will be addressed in future, the learning from this case will be taken to the governance, Clinical and Quality Lead and team meetings. In addition, details will be added to the assessment proforma around engagement with the next of kin to get collateral history and discuss concerns, if the patient consents to this. If the patient does not give consent, a mental capacity assessment will be conducted and documented around this decision and discussed at MDT with the lead clinician.” Source location Response from Whittington Health NHS Trust
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 The team had received and considered information about the patient’s unsafe home circumstances, neighbours and self-care difficulties.
Verbatim wording from the response “DT also had a mental health history and was paranoid. This was compounded by problems he’d experienced with neighbours and cuckooing concerns meaning that at times, he didn’t feel safe at home. It does not appear that these were factored into his inability to engage with the team.” Source location Response from Whittington Health NHS Trust
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 ICAT discharged the patient because other community services addressed all identified problems and provided a safety net for ongoing follow-up.
Verbatim wording from the response “In terms of the decision making around discharge, although Derrick’s refusal for ongoing assessment was a factor, the primary reason for discharge was that all the identified problems were being addressed by existing teams and ICAT could not add anything further to Derrick’s care. In addition, as he remained under Integrated Networks Coordinators (INC) and several other community services there was a safety net in place in terms of ongoing follow up.” Source location Response from Whittington Health NHS Trust
Open published response
8 Nov 2022 Roy Elton TRAVERS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 7 Delays in disclosing relevant review information to HM Coroner View source Uncertainty about discussion of patient care at the relevant morbidity and mortality meeting View source Failure to review deaths and learn lessons before inquest View source Uncertainty about provision of direct feedback and learning opportunities after identified clinical errors View source Failure to escalate clinically significant melaena for timely medical review View source Failure to provide non-discriminatory care for confused elderly patients View source Failure to withhold anticoagulation therapy when clinically indicated View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Roy Elton TRAVERS · 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
Roy Travers died on 6 June 2022 from a spontaneous cerebral bleed after admission to Whittington Hospital on 2 June, where he was not initially scanned and the bleed was not diagnosed. Concerns included delayed review after melaena was noted, failure to withhold apixaban, uncertainty about whether identified learning actions took place, and concerns about the treatment of Mr Travers and the late disclosure of the hospital’s review to the coroner and family.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in disclosing relevant review information to HM Coroner
Wider context from the report “5. As you will be aware, an ancillary function of every inquest is to attempt to learn lessons from the death, the driver behind prevention of future deaths reports. However, it is incumbent upon every hospital trust to consider the deaths of those within its care long before the matter comes to inquest, and to attempt to learn from these if possible.
Whittington Health conducted a 72 hour review of Mr Travers’ care on 17 June 2022.
This was disclosed to my coroner’s officer late on the afternoon of Friday, 4 November, in preparation for an inquest listed for 10am on Monday, 7 November.
This meant that Mr Travers’ family and I received the 72 hour review on the morning of inquest. This had several consequences.
• It placed family members in an unfair position in terms of their preparation for inquest.
• It did not comply with the duty to co-operate with HM Coroner, not simply when asked but also by volunteering all relevant information.
• It denied HMC the ability to call to inquest any witnesses the need for whom only became apparent from the review.
• And it did not inspire confidence that Whittington Health took its own review seriously and tried to learn from it. Even the Whittington consultant giving oral evidence at inquest only saw the review on the morning of inquest, and then purely as a result of being provided it by my coroner’s officer.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about discussion of patient care at the relevant morbidity and mortality meeting
Wider context from the report “3. The 72 hour review identified the need to discuss Mr Travers’ care at the relevant morbidity and mortality meeting. It is unclear from the review whether that discussion has taken place.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review deaths and learn lessons before inquest
Wider context from the report “5. As you will be aware, an ancillary function of every inquest is to attempt to learn lessons from the death, the driver behind prevention of future deaths reports. However, it is incumbent upon every hospital trust to consider the deaths of those within its care long before the matter comes to inquest, and to attempt to learn from these if possible.
Whittington Health conducted a 72 hour review of Mr Travers’ care on 17 June 2022.
This was disclosed to my coroner’s officer late on the afternoon of Friday, 4 November, in preparation for an inquest listed for 10am on Monday, 7 November.
This meant that Mr Travers’ family and I received the 72 hour review on the morning of inquest. This had several consequences.
• It placed family members in an unfair position in terms of their preparation for inquest.
• It did not comply with the duty to co-operate with HM Coroner, not simply when asked but also by volunteering all relevant information.
• It denied HMC the ability to call to inquest any witnesses the need for whom only became apparent from the review.
• And it did not inspire confidence that Whittington Health took its own review seriously and tried to learn from it. Even the Whittington consultant giving oral evidence at inquest only saw the review on the morning of inquest, and then purely as a result of being provided it by my coroner’s officer.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about provision of direct feedback and learning opportunities after identified clinical errors
Wider context from the report “2. As identified at the Whittington 72 hour review, the reviewing doctor who later considered Mr Travers’ condition in the light of the melaena, then failed to withhold his anti-coagulation therapy, apixaban. It is unclear from the review whether that doctor has since been given direct feedback and a learning opportunity.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate clinically significant melaena for timely medical review
Wider context from the report “1. Malaena was noted at 8.45am on 4 June 2022, but it was another 12 hours before medical staff reviewed Mr Travers. There appears to have been a failure to escalate. A doctor was asked to see him earlier that day, but about a different issue.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide non-discriminatory care for confused elderly patients
Wider context from the report “4. Mr Travers’ sons told me at inquest that, when Mr Travers’ was nursed on Mary Seacole Ward, they felt that staff regarded this confused, elderly man as a nuisance . That is clearly unacceptable. In addition, Mr Travers’ family worried that this view of him clouded the judgement of those looking after him .
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to withhold anticoagulation therapy when clinically indicated
Wider context from the report “2. As identified at the Whittington 72 hour review, the reviewing doctor who later considered Mr Travers’ condition in the light of the melaena, then failed to withhold his anti-coagulation therapy, apixaban . It is unclear from the review whether that doctor has since been given direct feedback and a learning opportunity.
” 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 Share learning from deaths through Grand Rounds, the Trust-wide Patient Safety newsletter and the monthly Patient Safety Forum.
Verbatim wording from the response “Learning from deaths have been shared in Grand rounds, highlighted in the Trust wide Patient Safety newsletter and the monthly Patient Safety Forum.” Source location Response from Whittington Health NHS Trust
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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 Introduce ward-nurse training on recognising and escalating gastrointestinal bleeding, led by the endoscopy nursing team.
Verbatim wording from the response “Further training for ward nurses is being put in place to cover the recognition and escalation of gastrointestinal bleeding is being organised by the Associate Director of Nursing and will be led by the endoscopy nursing team.” Source location Response from Whittington Health NHS Trust
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 Collate learning from deaths and report it quarterly to the Trust board-level Quality Assurance Meeting.
Verbatim wording from the response “Mortality review meetings are led by the department mortality leads. There is evidence to support that these meetings are taking place, including provision of timely mortality reviews. These meetings provide opportunities to capture and share the learning from death. This case was discussed at a Mortality Meeting on 21 July 2022. The Associate Medical Director for Patient Safety and Learning from deaths collates the learning and reports this to the Trust board level Quality Assurance Meeting on a quarterly basis. This has continued throughout the COVID-19 pandemic.” Source location Response from Whittington Health NHS Trust
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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 deteriorating-patient recognition and management training to ward nurses through the Critical Care Outreach Team.
Verbatim wording from the response “The Ward manager ████████ has given feedback to the nurse who did not escalate melaena. The nurse has booked to attend a course in January 2023 which includes how to recognise and manage the deteriorating patient. This course will re-enforce knowledge, improve competence, encourage better communication, and enhance team working. This course is run by the Critical Care Outreach Team.” Source location Response from Whittington Health NHS Trust
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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 Existing alerts, one-to-one supervision, documented support and staff skills were considered sufficient to manage the confused patient's needs safely.
Verbatim wording from the response “████████ Ward Manager of Mary Seacole, offers her sincere condolences to Mr Travers’ family. Ms Bakari advises Mr Travers had an electronic alert to notify staff of his additional care needs due to his dementia. Due to his risk of dehydration ████████ herself supported to insert a new intravenous cannula. A 1:1 was also implemented to support his safety (prevention of falls risks) whilst he was being nursed in a side room. There is clear documentation that nursing staff were supporting him with taking oral fluids and offering food and assisted him with his personal hygiene needs. Staff regularly care for patients with confusion but ████████ felt Mr Travers needs while confused were manageable on the ward and appropriate to the skills of the staff.” Source location Response from Whittington Health NHS Trust
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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 Existing mortality review meetings and reporting arrangements were considered sufficient to capture and share learning from deaths.
Verbatim wording from the response “Mortality review meetings are led by the department mortality leads. There is evidence to support that these meetings are taking place, including provision of timely mortality reviews. These meetings provide opportunities to capture and share the learning from death. This case was discussed at a Mortality Meeting on 21 July 2022. The Associate Medical Director for Patient Safety and Learning from deaths collates the learning and reports this to the Trust board level Quality Assurance Meeting on a quarterly basis. This has continued throughout the COVID-19 pandemic.” Source location Response from Whittington Health NHS Trust
Open published response
22 Feb 2021 Cecilia EDWARDS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Lack of clear protocols integrating agency district nurses into the organisation View source High proportion of district nursing care provided by agency nurses View source Failure to make immediate tissue viability referrals for category 3 pressure ulcers View source Failure to routinely coordinate district nurse and carer visits View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Cecilia EDWARDS · 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
Cecilia Edwards was admitted to Whittington Hospital on 26 September 2020 with a severe right elbow infection and died there two weeks later. The report identified concerns that a category 3 pressure ulcer was not referred promptly to a tissue viability nurse, that many visiting nurses were agency staff without clear protocols, and that nursing visits were not routinely coordinated with carers, resulting in incomplete care on some occasions.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear protocols integrating agency district nurses into the organisation
Wider context from the report “2. 60% of the district nurses who visited Cecilia Edwards were agency nurses. This is obviously undesirable in itself, although I recognise that it may be very difficult to address.
That notwithstanding, the district nurse team manager giving evidence in court agreed with Ms Edwards’ niece (herself a former district nurse and health visitor, and her auntie’s longstanding advocate) that clear protocols would raise standards, make mistakes less likely and bring the agency staff in as part of the organisation . Ultimately this would improve patient care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation High proportion of district nursing care provided by agency nurses
Wider context from the report “2. 60% of the district nurses who visited Cecilia Edwards were agency nurses . This is obviously undesirable in itself , although I recognise that it may be very difficult to address.
That notwithstanding, the district nurse team manager giving evidence in court agreed with Ms Edwards’ niece (herself a former district nurse and health visitor, and her auntie’s longstanding advocate) that clear protocols would raise standards, make mistakes less likely and bring the agency staff in as part of the organisation. Ultimately this would improve patient care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make immediate tissue viability referrals for category 3 pressure ulcers
Wider context from the report “1. On 12 February 2020, a district nurse assessed Ms Edwards’ elbow as a category 3 pressure ulcer, which should have prompted an immediate referral to the tissue viability nurse.
However, no such referral was made , either by the attending nurse; the district nurses who visited twice a week over the next seven months; the frequent care plan reviewers; or the shift co-ordinator until 22 September 2020 .
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely coordinate district nurse and carer visits
Wider context from the report “3. The district nurses who visited Cecilia Edwards needed the assistance of the two carers to turn her and attend to all her nursing needs, but sometimes when they visited there were no carers present and so the nursing care given was incomplete .
The carers attended at set hours four times a day, and so it seems that the onus was on the nursing team to arrange the twice weekly visits appropriately.
Sometimes, individual nurses would ring individual carers to make arrangements, but there was no organisational system to ensure that nurse and carer visits coincided as a matter of routine .
” 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 Revise daily handovers to include temporary staff and a specific pressure-ulcer management item, with regular senior-nurse monitoring.
Verbatim wording from the response “In addition, the daily handover process has been revised to ensure that all teams across the service have allocated time to attend, including temporary staff. Handover also now includes a specific item for pressure ulcer management. The District Nursing Leads (senior nurses) are monitoring handover on a regular basis to ensure the changes are embedded.” Source location 2021-0049-Response-from-Whittington-Hospital-Redacted
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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 Discuss care coordination with the family and caring nurse, agree the plan, and document it in the electronic care plan.
Verbatim wording from the response “There are robust arrangements established with local social care agencies and the District Nursing service. However, in this case there was a private carer arrangement, funded and organised by the family. This requires an individualised approach by the service to co-ordinate the care with families to meet specific requirements of the patient. The service has reviewed how it works with families in these circumstances and going forward there will be a discussion with the family and the nurse caring for the patient on this. The plan of care and working together will be agreed with the family and service and will be clearly documented in the electronic patient record care plan.” Source location 2021-0049-Response-from-Whittington-Hospital-Redacted
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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 Monitor family care-coordination arrangements through senior-nurse review, case-note audits and caseload reviews.
Verbatim wording from the response “This will be monitored on a regular basis by the senior nurses and included in future case note audits and caseload reviews.” Source location 2021-0049-Response-from-Whittington-Hospital-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and formally ratify Tissue Viability Nursing referral guidance, following staff consultation, with regular compliance audits.
Verbatim wording from the response “Whittington Health has reviewed the process for referral to the Tissue Viability Nursing service (TVN) and is formally revising the ‘Referral to TVN guidance’ to ensure timely referrals are made based on clinical need and categorisation, and not purely based on categorisation alone. The new guidance will undertake regular audit practice to monitor compliance. The guidance will be formally ratified in August 2021, following consultation with staff.” Source location 2021-0049-Response-from-Whittington-Hospital-Redacted
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 Recruit substantive and bank district-nursing staff through local and international recruitment.
Verbatim wording from the response “Work is also ongoing to recruit to the District Nursing service, both for substantive roles and on the Bank, both locally and internationally. The Trust actively works with agency staff who are regular workers to consider joining the organisation as permanent employees and they are offered several flexible options to meet their personal circumstances. Vacancies are monitored through the Trust divisional reporting structure and at the Trust workforce committee.” Source location 2021-0049-Response-from-Whittington-Hospital-Redacted
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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 Work with regular agency staff to support their transition into permanent employment through flexible options.
Verbatim wording from the response “Work is also ongoing to recruit to the District Nursing service, both for substantive roles and on the Bank, both locally and internationally. The Trust actively works with agency staff who are regular workers to consider joining the organisation as permanent employees and they are offered several flexible options to meet their personal circumstances. Vacancies are monitored through the Trust divisional reporting structure and at the Trust workforce committee.” Source location 2021-0049-Response-from-Whittington-Hospital-Redacted
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 the referral process for Tissue Viability Nursing referrals.
Verbatim wording from the response “Whittington Health has reviewed the process for referral to the Tissue Viability Nursing service (TVN) and is formally revising the ‘Referral to TVN guidance’ to ensure timely referrals are made based on clinical need and categorisation, and not purely based on categorisation alone. The new guidance will undertake regular audit practice to monitor compliance. The guidance will be formally ratified in August 2021, following consultation with staff.” Source location 2021-0049-Response-from-Whittington-Hospital-Redacted
Open published response
31 Jul 2019 Fern-Marie CHOYA · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure to include pregnancy information in pre-hospital alerts View source Failure to involve the obstetric team in the assessment and management of pregnant emergencies View source Failure to communicate pregnancy information effectively on hospital arrival View source Delays in recognising pregnancy and calling the obstetric team View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Fern-Marie CHOYA · 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
Fern-Marie Choya died from hypovolaemic shock caused by massive intra-abdominal bleeding following rupture of the abdominal gravid uterus during a monochorionic diamniotic pregnancy. Concerns included failure to communicate her pregnancy during the pre-hospital alert and on hospital arrival, a 16-minute delay in recognising the pregnancy and calling the obstetric team, and treatment focused on possible pulmonary embolism before free fluid was identified.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include pregnancy information in pre-hospital alerts
Wider context from the report “1. The London Ambulance Service (LAS) emergency operations centre (EOC) made a pre hospital alert telephone call to the Whittington Hospital emergency department, regarding the expected arrival eight minutes later of a patient in respiratory arrest. This was good practice.
However, they failed to include in that alert the information that Ms Choya was pregnant . This was a crucial detail, which had been passed to the LAS at the very outset by her husband, and then again to the EOC by the emergency medical crew on scene.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve the obstetric team in the assessment and management of pregnant emergencies
Wider context from the report “3. Without the obstetric team, the emergency department team focus was on the potential for a pulmonary embolism, and alteplase was given. Only later was a scan conducted and free fluid noted. By the time of the laparotomy it was too late to save Ms Choya.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate pregnancy information effectively on hospital arrival
Wider context from the report “2. On arrival at the Whittington Hospital, the detail of the pregnancy was not communicated effectively .
It is unclear whether the LAS crew did not mention the fact, or whether the emergency staff simply did not hear it.
In any event, it took 16 minutes post arrival for the pregnancy to be recognised and the obstetric team to be called.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in recognising pregnancy and calling the obstetric team
Wider context from the report “2. On arrival at the Whittington Hospital, the detail of the pregnancy was not communicated effectively.
It is unclear whether the LAS crew did not mention the fact, or whether the emergency staff simply did not hear it.
In any event, it took 16 minutes post arrival for the pregnancy to be recognised and the obstetric team to be called .
” 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 Launch criteria for initiating an obstetric call before a patient's arrival, jointly agreed by obstetric and emergency teams.
Verbatim wording from the response “2. A set of criteria have been developed to determine if an obstetric call needs to be initiated prior to patient arrival. The Trust already has a process in place for trauma calls, which has now been expanded to cover obstetric callout criteria. In agreeing the criteria, advice was sought from Emergency Department colleagues in other trusts to see if similar systems were already in place and the final criteria were agreed jointly with our obstetrics and emergency teams. The new criteria have now been launched in the Emergency Department. A copy of the criteria is included in Appendix B.” Source location 2019-0281-Resposne-by-Whittington-Health-NHS-Trust
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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 Design SBAR handover into electronic clinical notes used from patient presentation through discharge.
Verbatim wording from the response “4. Further work is being undertaken across the Trust in order to standardise handover between clinicians by using the “SBAR” format (Situation, Background, Assessment, Recommendation). This has already been included in the new junior doctor’s induction to the Emergency Department and is being designed into the electronic clinical notes that are used to hand over a patient at any point from presentation to discharge.” Source location 2019-0281-Resposne-by-Whittington-Health-NHS-Trust
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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 Include SBAR handover training in the Emergency Department junior doctors' induction.
Verbatim wording from the response “4. Further work is being undertaken across the Trust in order to standardise handover between clinicians by using the “SBAR” format (Situation, Background, Assessment, Recommendation). This has already been included in the new junior doctor’s induction to the Emergency Department and is being designed into the electronic clinical notes that are used to hand over a patient at any point from presentation to discharge.” Source location 2019-0281-Resposne-by-Whittington-Health-NHS-Trust
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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 Replace the Emergency Department priority-call information sheet with a version prompting staff to ask whether a relevant patient is pregnant.
Verbatim wording from the response “1. We have modified the Emergency Department ‘Priority call information sheet’ which is used when recording call details received from London Ambulance Service red phone. The sheet now includes a prompt for Whittington Health staff to ask if the patient is pregnant, where relevant. This new sheet replaced the original form in the” Source location 2019-0281-Resposne-by-Whittington-Health-NHS-Trust
Open published response
14 Aug 2018 Enric Albert Alejandro Elliott · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2 Gestational barriers to referral of young women who book late to the Family Nurse Partnership View source Failure to recognise late booking as a positive referral reason for vulnerable mothers and babies View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Enric Albert Alejandro Elliott · 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
Enric Albert Alejandro Elliott was found not breathing at home on 20 November 2017, was resuscitated and transferred to hospital, and died there on 24 November 2017 at five months old. The report raised concerns that late-booking young and vulnerable mothers could be excluded from Family Nurse Partnership support because of gestational-age referral rules, potentially increasing risks to their children.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Gestational barriers to referral of young women who book late to the Family Nurse Partnership
Wider context from the report “1. That young women who book later than 28 weeks can only be considered for referral to the Family Nurse Partnership , despite the fact that late booking is often a further risk factor indicating increased vulnerability to the mother and young child.
2. That late bookers may still be debarred from referral on the basis of gestation .
3. That such vulnerable mothers are thus excluded from the support offered by the Family Nurse Partnership and thus their child be at increased risk of death in infancy.
4. That the increased risk to mothers and babies of late booking does not appear to be recognised as a positive reason supporting referral to the Family Nurse partnership.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise late booking as a positive referral reason for vulnerable mothers and babies
Wider context from the report “1. That young women who book later than 28 weeks can only be considered for referral to the Family Nurse Partnership, despite the fact that late booking is often a further risk factor indicating increased vulnerability to the mother and young child .
2. That late bookers may still be debarred from referral on the basis of gestation.
3. That such vulnerable mothers are thus excluded from the support offered by the Family Nurse Partnership and thus their child be at increased risk of death in infancy.
4. That the increased risk to mothers and babies of late booking does not appear to be recognised as a positive reason supporting referral to the Family Nurse partnership.
” 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 Consider, case by case, accepting willing referrals after 28 weeks’ gestation where additional vulnerabilities or concealed pregnancy are present.
Verbatim wording from the response “As a result of your PFD, we have agreed that we can consider with the London FNP team, on a case by case basis, accepting referrals for mothers who are willing to engage with the FNP programme when they are referred after 28 weeks gestation, particularly when there are a further range of needs, vulnerabilities and issues associated with concealed pregnancy.” Source location 2018-0300-Response-by-Whittington-Health-NHS-Trust
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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 Meet with commissioners and the national FNP Team to agree further local flexibility in programme delivery.
Verbatim wording from the response “Following your PFD, our Trust FNP lead has met with both our local commissioners and the national FNP Team to agree how we can further implement local flexibility to the delivery of the FNP programme.” Source location 2018-0300-Response-by-Whittington-Health-NHS-Trust
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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 FNP’s existing 28-week recruitment threshold remains appropriate because therapeutic relationships require time to form, subject to limited case-by-case referrals and testing.
Verbatim wording from the response “As a result of your PFD, we have agreed that we can consider with the London FNP team, on a case by case basis, accepting referrals for mothers who are willing to engage with the FNP programme when they are referred after 28 weeks gestation, particularly when there are a further range of needs, vulnerabilities and issues associated with concealed pregnancy.” Source location 2018-0300-Response-by-Whittington-Health-NHS-Trust
Open published response
24 May 2017 Dominic Michael WHITE · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Inadequate clinical decision-making for granting leave to detained patients at risk of absconding View source Failure to ensure that all relevant personnel are aware of the patient’s mental health observation level View source
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
Dominic Michael 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
Dominic White, who had bipolar affective disorder and psychosis, rapidly deteriorated over several days and was assessed as requiring detention under section 2 of the Mental Health Act. Before he could be conveyed to a mental health hospital, he left the emergency unit and was found the following day at an electricity substation with injuries consistent with a fall from height. The concerns included whether mental health observation levels were communicated effectively and the clinical decision-making involved in allowing him to leave after detention had been decided.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical decision-making for granting leave to detained patients at risk of absconding
Wider context from the report “2. The C&I approved mental health professional (AMHP) who gave Mr White permission to leave the hospital to go to McDonald’s, after the decision had been made to detain him under section 2 of the Mental Health Act, acknowledged that she should have discussed this first with a colleague.
However, she remained of the view at inquest that the decision itself had been the right one. Proof of this, she explained, was the fact that Mr White did return to the hospital from this visit.
Allowing leave in these circumstances was a very unusual step I am concerned at the lack of recognition, even so long after the event, that allowing a person to leave the hospital in these circumstances:
- was not necessarily the right one simply because the patient returned on this occasion (he left again within half an hour and never returned); and
- had the potential to lull others into a false sense of security about his risk of absconding .
The trust’s root cause analysis action plan merely describes the need to have legally authorised permission to leave, without addressing any question of how to shape clinical decision making .
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that all relevant personnel are aware of the patient’s mental health observation level
Wider context from the report “1. I heard that, following Mr White’s death, the level of (mental health) observations of a patient at the Whittington Hospital Emergency Unit is now clearly documented.
However, I am not sure that there is yet a robust protocol in place to ensure that all relevant personnel (Whittington EU doctors, nurses and security officers; also visiting independent s12 doctors, BEH and C&I staff) are aware of the level .
My concern arises because sometimes, when anyone can look at a record, that nobody actually does .
” Open source report
24 Feb 2017 Doreen Elma STAPLETON · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to provide explicit discharge advice about the fatal consequences of district nursing visits and medication administration not taking place View source Failure to provide district nursing contact details and missed-visit escalation instructions at discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Doreen Elma STAPLETON · 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
Doreen Stapleton died at Whittington Hospital on 15 September 2016 from a pulmonary thromboembolism, after previously being diagnosed with pulmonary emboli. Following discharge, district nurses were intended to administer daily tinzaparin injections, but the referral was not received because an obsolete email address was used. The principal concern was that Doreen and her sons were not given sufficiently explicit advice about the potentially fatal consequences of missed medication and were not given the district nursing team’s telephone number or told to call if nurses did not attend.
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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide explicit discharge advice about the fatal consequences of district nursing visits and medication administration not taking place
Wider context from the report “When she was discharged, although the plan of daily district nursing visits was made clear to her, no member of the team had another very explicit conversation with her or with her two sons, about the potential consequence (i.e. death) of the visits and medication administration not taking place . She and her sons were not given the telephone number of the district nursing team and were not told to ring if nurses failed to attend the following day. I understand that patients are now all given a leaflet with the district nursing team telephone number, but I am concerned that there is still a lack of emphasis on this aspect of discharge advice .
I heard from one witness that this is a whole team responsibility. Any member of the team – consultant physician, consultant psychiatrist, discharge nurse – could have had this very direct conversation with Ms Stapleton and her family, but nobody did . I appreciate that there may be a reluctance to be so blunt because of a fear of scaring patients, but any reluctance must be overcome in certain situations if patients are to be supported in the best way possible. Indeed, it had already been overcome by one consultant earlier in Ms Stapleton’s admission.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide district nursing contact details and missed-visit escalation instructions at discharge
Wider context from the report “When she was discharged, although the plan of daily district nursing visits was made clear to her, no member of the team had another very explicit conversation with her or with her two sons, about the potential consequence (i.e. death) of the visits and medication administration not taking place. She and her sons were not given the telephone number of the district nursing team and were not told to ring if nurses failed to attend the following day . I understand that patients are now all given a leaflet with the district nursing team telephone number, but I am concerned that there is still a lack of emphasis on this aspect of discharge advice .
I heard from one witness that this is a whole team responsibility. Any member of the team – consultant physician, consultant psychiatrist, discharge nurse – could have had this very direct conversation with Ms Stapleton and her family, but nobody did. I appreciate that there may be a reluctance to be so blunt because of a fear of scaring patients, but any reluctance must be overcome in certain situations if patients are to be supported in the best way possible. Indeed, it had already been overcome by one consultant earlier in Ms Stapleton’s admission.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to doctors, senior nurses and pharmacists highlighting learning points for embedding in clinical practice.
Verbatim wording from the response “1) ████████ and I, as Director of Nursing and Patient Experience and Executive Medical Director respectively, will write to our doctors and senior nurses and pharmacists to highlight what we think are the key learning points that arise out of your concerns, so that they can consider how to embed these in their clinical practice from now on.” Source location Doreen-Stapleton-Response-by-Whittington-Health-NHS_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning with inpatient pharmacists to support patients’ understanding of medication significance at discharge.
Verbatim wording from the response “5) I have asked our Chief Pharmacist to share this learning with all pharmacists on our inpatient wards so that they can make an important contribution to ensuring that patients understand the significance of their medication on discharge.” Source location Doreen-Stapleton-Response-by-Whittington-Health-NHS_Redacted
Open published response
12 Nov 2015 Matthew Marc GROOM · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Failure to convey the need for urgent police intervention in a welfare-check request View source Delays in arranging immediate mental health assessment View source Failure to administer prescribed medication View source Failure to plan action if a mental health assessment is interrupted by a patient leaving View source Failure to seek urgent hospital security assistance when detention under the Mental Health Act is considered necessary View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Matthew Marc GROOM · 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
Matthew Marc Groom stood in front of a lorry after spending seven hours in the emergency unit of Whittington Hospital, where he was seen by emergency medicine and mental health staff. Concerns included delays in his mental health assessment, prescribed diazepam not being administered, inadequate planning for his possible departure, failure to seek urgent hospital security assistance, and incomplete communication with police.
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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to convey the need for urgent police intervention in a welfare-check request
Wider context from the report “5. The nurse who then contacted the police did not then convey this to them , but requested a welfare check that would be satisfied by knowing he was with a family member .
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in arranging immediate mental health assessment
Wider context from the report “1. Most importantly, Matt Groom waited four hours in the emergency unit before he saw a mental healthcare professional for the first time . I heard that, at the time in these circumstances, it was not possible for a triage nurse to arrange for immediate mental health 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer prescribed medication
Wider context from the report “2. Diazepam was prescribed but never administered .
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to plan action if a mental health assessment is interrupted by a patient leaving
Wider context from the report “3. The mental health nurse who then saw him did not consider what action to take if he should suddenly decide to leave , most particularly given that she felt unable to conclude the assessment without waiting for a doctor to come in from home to assist .
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek urgent hospital security assistance when detention under the Mental Health Act is considered necessary
Wider context from the report “4. When Matt did leave the department, the assessing doctor asked the nurse to call the police, but neither doctor nor nurse considered seeking urgent assistance from hospital security , given that they were by now both of the view that he would probably now have to be detained under section of the Mental Health Act .
” Open source report
19 Oct 2015 Vasilis KTORAKIS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 7 Failure to conduct a timely full clinical review View source Failure to include involved registrars’ input in untoward incident investigations View source Failure to provide appropriate feedback after a clinical error View source Failure to notify involved registrars of incident investigation findings View source Delay in commencing Syntocinon View source Failure to adequately record a management plan View source Lack of a robust system for learning lessons View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Vasilis KTORAKIS · 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
Baby Vasilis was born in an extremely poor condition following a long labour at Whittington Hospital on 23 May 2015 and died shortly thereafter. The report identified concerns about the timing of Syntocinon, inadequate recording of a management plan, a registrar’s decision regarding passive descent, and failures to involve staff in the investigation and communicate its findings for learning.
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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a timely full clinical review
Wider context from the report “1. ████████ was started on Syntocinon at 7.15pm on Friday, 22 May 2015. Given the circumstances of her presentation (including meconium stained liquor and infrequent contractions at a late stage of labour), her consultant told me in court that when ████████ was seen by a registrar at 2.40pm that afternoon , the registrar should have conducted a full review and started Syntocinon then, some four and a half hours before.
Having spoken to the registrar since, the consultant is unable to explain why that full review and medication commencement did not take place. It is therefore unclear whether this particular registrar, and indeed others on the unit, might be likely to make the same mistake again another time.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include involved registrars’ input in untoward incident investigations
Wider context from the report “4. The first registrar was not asked to contribute to the hospital’s untoward incident investigation , so there was a systemic failure to understand the value of her input , resulting in a loss of learning for the organisation and for the registrar.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate feedback after a clinical error
Wider context from the report “3. At ten past midnight on Saturday, 23 May, a different registrar took the decision to allow two hours passive descent before pushing. This was an error of judgement that the registrar had not appreciated even by the time of the inquest, over four months after death, indicating that she had not received appropriate feedback. It is therefore unclear whether this particular registrar, and others on the unit, might be likely to make this same mistake 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify involved registrars of incident investigation findings
Wider context from the report “5. Neither the first nor the second registrar was notified of the untoward incident investigation findings, even by the time of inquest , and so the opportunity for them to learn and to improve was lost . This seems to demonstrate a lack of a robust system for learning lessons.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in commencing Syntocinon
Wider context from the report “1. ████████ was started on Syntocinon at 7.15pm on Friday, 22 May 2015. Given the circumstances of her presentation (including meconium stained liquor and infrequent contractions at a late stage of labour), her consultant told me in court that when ████████ was seen by a registrar at 2.40pm that afternoon, the registrar should have conducted a full review and started Syntocinon then, some four and a half hours before.
Having spoken to the registrar since, the consultant is unable to explain why that full review and medication commencement did not take place . It is therefore unclear whether this particular registrar, and indeed others on the unit, might be likely to make the same mistake again another time.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately record a management plan
Wider context from the report “2. The notes recorded by that registrar fell significantly short of what can be expected in terms of recording a management plan.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust system for learning lessons
Wider context from the report “5. Neither the first nor the second registrar was notified of the untoward incident investigation findings, even by the time of inquest, and so the opportunity for them to learn and to improve was lost. This seems to demonstrate a lack of a robust system for learning lessons.
” Open source report
29 Apr 2015 Finnulla Catherine MARTIN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 13 Failure to obtain the triage record before patient assessment View source Unavailability of triage records of patient attendance View source Failure to ask patients about thoughts of suicide View source Failure to establish the circumstances leading to police involvement and the identity of the caller View source Lack of clarity about protocols for receiving information from police officers accompanying voluntary patients View source Delays in passing family information to the psychiatry liaison team View source Confusion about voluntary attendance of patients with mental health needs accompanied by police View source Failure to record calls from family members to the emergency department View source Failure to characterise urgent police contact as an emergency after a patient leaves hospital View source Failure to obtain collateral history from family members before concluding the interview View source Confusion about voluntary attendance of patients with mental health needs accompanied by police View source Failure to record critical information disclosed to police call handlers View source Failure to ask patients about thoughts of harming another person View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Finnulla Catherine MARTIN · 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
Finnulla Catherine Martin took her own life by jumping from the sixth-floor balcony of her home less than an hour after discharge from Whittington Hospital following a mental health assessment. Concerns included failures to obtain and share relevant information, incomplete assessment of suicide and harm risks, inadequate collateral history-taking, uncertainty about procedures for police-accompanied voluntary attendance, and failure to characterise the police contact as an emergency after Ms Martin left hospital.
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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain the triage record before patient assessment
Wider context from the report “2. The team then saw a patient without waiting to obtain the triage record created by Whittington Hospital Trust staff.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of triage records of patient attendance
Wider context from the report “2. I was told at inquest by Camden & Islington that the Whittington had been unable to locate the Whittington triage record of Ms Martin’s attendance , and I did not discover any record of the call made by Ms Martin’s sister to the emergency department that night.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ask patients about thoughts of suicide
Wider context from the report “3. The doctor did not ask Ms Martin about thoughts of suicide within the context of her earlier declaration that she would die that night.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the circumstances leading to police involvement and the identity of the caller
Wider context from the report “5. He did not address his mind to what had led up to the police being called for Ms Martin, nor who had called them .
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about protocols for receiving information from police officers accompanying voluntary patients
Wider context from the report “1. It seemed from the evidence I heard that the Camden and Islington Trust psychiatry liaison team (doctor and nurse) operating at Whittington Hospital on the night of 15 November 2015, were not wholly clear about the protocols for receipt of information from police officers bringing patients into hospital on a voluntary basis .
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in passing family information to the psychiatry liaison team
Wider context from the report “8. The crisis team did not pass on information received from Ms Martin’s sister to the psychiatry liaison team with a sufficient degree of urgency to ensure that this was taken into consideration before the interview with Ms Martin was concluded.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Confusion about voluntary attendance of patients with mental health needs accompanied by police
Wider context from the report “2. As I have indicated above, the confusion surrounding voluntary attendance of a patient with mental health needs accompanied by the police , suggests a multi agency discussion and agreement would be beneficial.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record calls from family members to the emergency department
Wider context from the report “2. I was told at inquest by Camden & Islington that the Whittington had been unable to locate the Whittington triage record of Ms Martin’s attendance, and I did not discover any record of the call made by Ms Martin’s sister to the emergency department that night .
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to characterise urgent police contact as an emergency after a patient leaves hospital
Wider context from the report “7. When they obtained this afterwards and then realised that Ms Martin had left the hospital, they contacted the police but did not characterise this as an emergency .
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain collateral history from family members before concluding the interview
Wider context from the report “6. Neither doctor nor nurse obtained a collateral history of events from a family member before concluding their interview with Ms Martin.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Confusion about voluntary attendance of patients with mental health needs accompanied by police
Wider context from the report “1. There seemed to be some degree of confusion surrounding the voluntary attendance of a patient with mental health needs accompanied by the police , that suggests a multi agency discussion and agreement would be beneficial.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record critical information disclosed to police call handlers
Wider context from the report “1. The police call handler who spoke to Ms Martin did not record that she said: “I need to jump a balcony” . This was important information.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ask patients about thoughts of harming another person
Wider context from the report “4. He did not ask her about any thoughts of harming another person , regardless of the fact he was not aware that she had threatened this.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree which aspects of the Medway system Camden and Islington staff will use.
Verbatim wording from the response “Recommendation: For all Camden and Islington Foundation Trust employees and associated locum staff to have good understanding of the Emergency Department computer system “Medway” to improve information available to them” Source location 2015-0173-Whittington-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a written Medway user guide for Camden and Islington staff.
Verbatim wording from the response “Key Action(s):
Provide written guide on use of Emergency Department computer system” Source location 2015-0173-Whittington-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and finalise Emergency Department guidelines for patients brought by police.
Verbatim wording from the response “a) Development of care guidelines relating to patients brought into the Emergency Department by the police.” Source location 2015-0173-Whittington-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree a local standard operating procedure for recording calls to the Emergency Department.
Verbatim wording from the response “To agree a local standard operating procedure” Source location 2015-0173-Whittington-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Repeat training for Camden and Islington staff on the Medway system.
Verbatim wording from the response “To repeat training on the Medway system” Source location 2015-0173-Whittington-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot the mental health assessment proforma and make it available to mental health colleagues.
Verbatim wording from the response “b) To implement use of a mental health Proforma to improve the quality of assessments and ensure this is available to mental health colleagues” Source location 2015-0173-Whittington-Health-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The triage assessment was recorded electronically, including the patient’s arrival, assessment, police attendance and high risk of self-harm.
Verbatim wording from the response “Whittington Health response – all triage assessments are recorded electronically. Patient FM was triaged. Arrived with police at 21:00 and was assessed and triaged at 21:15:
Pt brought in by police c/o suicidal ideations. Family concerned about patient. Patient voluntary. pmh: unknown.
National Triage category – mental illness – category 2 very urgent- discriminator – high risk of self-harm” Source location 2015-0173-Whittington-Health-NHS-Trust
Open published response
8 May 2014 Frank POPE · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Lack of a back-up process for patients who lack capacity to make decisions about attending follow-up consultations View source Failure to involve family members in follow-up correspondence where patients lack capacity to make decisions about attending follow-up consultations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Frank POPE · 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
Frank Pope had ischaemic heart disease, peripheral vascular disease and an abdominal aortic aneurysm, and was admitted to hospital several times in 2013 for ischaemic colitis. He died on 12 December 2013 after rapidly deteriorating from a further episode of ischaemic colitis; concerns were raised that patients who lack capacity to manage follow-up appointments may miss them when family members are not included in correspondence, with no clear backup process identified.
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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a back-up process for patients who lack capacity to make decisions about attending follow-up consultations
Wider context from the report “(1) Mr Pope’s family had concerns, which I share, that where a patient does not have capacity to make decisions about attending follow-up consultations, appointments might be missed when family members are not copied into correspondence. It was accepted that patient confidentiality would normally preclude such direct family involvement but that there may be circumstances when it is in the patient’s best interests to use this approach, to ensure follow-up occurs.
It was not clear from the evidence heard at the inquest what steps are taken when a patient is deemed not to have capacity to make this type of health decision . Concerns were raised that there is no ‘back-up’ process in place and that future deaths could occur as a consequence.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve family members in follow-up correspondence where patients lack capacity to make decisions about attending follow-up consultations
Wider context from the report “(1) Mr Pope’s family had concerns, which I share, that where a patient does not have capacity to make decisions about attending follow-up consultations, appointments might be missed when family members are not copied into correspondence . It was accepted that patient confidentiality would normally preclude such direct family involvement but that there may be circumstances when it is in the patient’s best interests to use this approach, to ensure follow-up occurs.
It was not clear from the evidence heard at the inquest what steps are taken when a patient is deemed not to have capacity to make this type of health decision. Concerns were raised that there is no ‘back-up’ process in place and that future deaths could occur as a consequence.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send GPs a bulletin reminding them to identify vulnerable or capacity-lacking patients and request copied appointment letters for nominated representatives.
Verbatim wording from the response “To conclude, I hope you are assured that the Trust has appropriate and robust processes in place with respect to patients who lack capacity to make decisions to attend their out-patient appointments. Having considered your recommendation, we do not feel that our processes or the Elective Access Policy require any changes; however we do feel it would be helpful to send a communication to all the GPs in our area reminding them of our safety net processes for patients who lack capacity to attend appointments.” Source location 2014-0216-Response-by-Whittington-Health-NHS
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 Existing processes and the Elective Access Policy are considered sufficient for supporting patients who lack capacity to attend appointments, so no changes are required.
Verbatim wording from the response “If a patient is deemed not to have capacity, and a formal letter or email request from the GP, family member/representative or clinician is made to the Patient Access Centre, an alert will be raised prompting the staff to copy appointment letters for that patient to family members, GP or the appointed representative. The Patient Access Supervisor will place the alert on the Trust’s Patient Administration System, which flags this request each time a member of staff makes an appointment. The system will show the name and address of the person to whom the copies should be sent. Unfortunately in Mr Pope’s case, such an alert was not requested and therefore his out-patient appointment letters were not copied to anyone. Had such a request been received for Mr Pope, we would have been accommodated it, as described.” Source location 2014-0216-Response-by-Whittington-Health-NHS
Open published response
3 Dec 2013 Agostino COSTA · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Lack of clarity among staff about falls risk classification View source Failure to share root cause analysis learning with relevant staff View source Failure to ensure staff competence in managing patients after falls View source
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
Agostino COSTA · 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
Agostino Costa died after an accidental fall in hospital on 12 May 2013, which hastened death from terminal disease. The principal concerns were staff confusion about falls-risk classification and management, inadequate training for a junior doctor, limited sharing of the hospital root cause analysis, and non-mandatory attendance at falls-prevention seminars.
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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity among staff about falls risk classification
Wider context from the report “1. There was confusion among the staff as to whether Mr Costa was classified as red (high risk) or green (low risk) in terms of falls.
2. There was confusion among the staff as to whether a patient walking with a frame presents a high risk of falls.
3. There was confusion among the staff as to whether a patient with myelofibrosis and blood transfusions presents a high risk of falls. This confusion was also present in the hospital root cause analysis conducted after Mr Costa’s death.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share root cause analysis learning with relevant staff
Wider context from the report “4. The junior doctor present did not know how to deal with a patient post fall on the ward, though he had dealt with patients in the emergency unit who had fallen in the community. He had not attended the hospital training seminar on falls.
5. The hospital root cause analysis was not shared with all relevant members of staff , though it was signed off at the beginning of August. Thus learning points from it were completely lost to some.
I heard that a great deal of work is being done in your trust to attempt to prevent falls and appropriately to treat patients when falls have occurred, but attendance at one of the monthly seminars run by the lead doctor for falls is not mandatory for all staff.
” 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 Whittington Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff competence in managing patients after falls
Wider context from the report “4. The junior doctor present did not know how to deal with a patient post fall on the ward , though he had dealt with patients in the emergency unit who had fallen in the community. He had not attended the hospital training seminar on falls.
5. The hospital root cause analysis was not shared with all relevant members of staff, though it was signed off at the beginning of August. Thus learning points from it were completely lost to some.
I heard that a great deal of work is being done in your trust to attempt to prevent falls and appropriately to treat patients when falls have occurred, but attendance at one of the monthly seminars run by the lead doctor for falls is not mandatory for all staff .
” 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