PFD report

Trevor John CURRY · Prevention of Future Deaths report

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Issued 17 Mar 2017•Brighton and Hove

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to ascertain and access patients’ full past medical histories promptly
    Part of recurring concern: Incomplete clinical history-taking
  2. Failure to record relevant disclosed cardiac history in psychiatric admission notes
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Brief staff on documentation concerns through Trust-wide communications, team meetings and clinical supervision.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2024.
  2. Action

    Audit ward documentation to check compliance with expected recording standards.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2024.
  3. Action

    Circulate and display primary-care-information guidance and provide it to new junior doctors through induction materials.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2024.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to ascertain and access patients’ full past medical histories promptly

Wider context from the report

“(1) It is nationally acknowledged that there are a growing number of patients in both acute and psychiatric hospitals and prisoners who have substantial mental health and physical problems. This is particularly the case in view of the ageing hospital and prison population. It is therefore incumbent upon those caring for such people to ensure that they have full mental and physical past medical histories. In this particular case at Inquest, I accepted that the deceased’s sister had informed the triaging and admitting staff at the psychiatric hospital of the fact that he was being seen by the Cardiologist and was suffering with heart problems (i.e. palpitations). No note was made of this in Mr Curry’s admitting note. It should have been. In addition, the psychiatric trust made no effort to ascertain his full past physical history until after he had died. Of course they were not expecting him to die within 48 hours of admission but that is not the point. Enquiries of this nature should be made at the earliest opportunity and if there are no reciprocal IT arrangements then the individual trusts must have arrangements between them so that they can access appropriate history speedily. This is particularly important in cases where a patient is admitted to a psychiatric hospital in an agitated, even psychotic state and unable to give an appropriate history him or herself. ”

Is this part of a recurring concern?

Yes — Incomplete clinical history-taking.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to record relevant disclosed cardiac history in psychiatric admission notes

Wider context from the report

“(1) It is nationally acknowledged that there are a growing number of patients in both acute and psychiatric hospitals and prisoners who have substantial mental health and physical problems. This is particularly the case in view of the ageing hospital and prison population. It is therefore incumbent upon those caring for such people to ensure that they have full mental and physical past medical histories. In this particular case at Inquest, I accepted that the deceased’s sister had informed the triaging and admitting staff at the psychiatric hospital of the fact that he was being seen by the Cardiologist and was suffering with heart problems (i.e. palpitations). No note was made of this in Mr Curry’s admitting note. It should have been. In addition, the psychiatric trust made no effort to ascertain his full past physical history until after he had died. Of course they were not expecting him to die within 48 hours of admission but that is not the point. Enquiries of this nature should be made at the earliest opportunity and if there are no reciprocal IT arrangements then the individual trusts must have arrangements between them so that they can access appropriate history speedily. This is particularly important in cases where a patient is admitted to a psychiatric hospital in an agitated, even psychotic state and unable to give an appropriate history him or herself. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Brief staff on documentation concerns through Trust-wide communications, team meetings and clinical supervision.

Verbatim wording from the response

“I am sorry, the information from Mr Curry’s sister that Mr Curry was being seen by a cardiologist and he was suffering with palpitations was not recorded in the health records. ████████, General Manager - Acute and Urgent Care Services for Brighton and Hove drafted a briefing for staff highlighting your concerns to ensure the lessons are widespread throughout the Trust. The briefing and ongoing team meetings and clinical supervision sessions have been used highlight the importance of good clear documentation in our new electronic health records system. This has assisted our learning and an improvement in our recording. Senior members of staff such as Ward Managers and Matrons at Mill View Hospital complete documentation audits to ensure the expected standards of documentation are met.”

Source location

Response from Sussex Partnership NHS Foundation Trust
Page 1 · response
Published 23 February 2024

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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

Audit ward documentation to check compliance with expected recording standards.

Verbatim wording from the response

“I am sorry, the information from Mr Curry’s sister that Mr Curry was being seen by a cardiologist and he was suffering with palpitations was not recorded in the health records. ████████, General Manager - Acute and Urgent Care Services for Brighton and Hove drafted a briefing for staff highlighting your concerns to ensure the lessons are widespread throughout the Trust. The briefing and ongoing team meetings and clinical supervision sessions have been used highlight the importance of good clear documentation in our new electronic health records system. This has assisted our learning and an improvement in our recording. Senior members of staff such as Ward Managers and Matrons at Mill View Hospital complete documentation audits to ensure the expected standards of documentation are met.”

Source location

Response from Sussex Partnership NHS Foundation Trust
Page 1 · response
Published 23 February 2024

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

Circulate and display primary-care-information guidance and provide it to new junior doctors through induction materials.

Verbatim wording from the response

“practice for all new patients admitted to Mill View hospital. This is done within 48 hours of admission and the administrators verify all new patient admissions at the daily Acute Referral Meeting (ARM) which is attended by the Bed Manager. The Crisis Resolution and Home Treatment Team administrators upload the primary care, summary care record / encounter report to the Trust’s electronic health records system ‘Carenotes’ which all clinical staff in the Trust have access to. Laminated copies of the guidance has been circulated to the wards at Mill View Hospital and it is displayed for staff as a reminder and for easy reference. Please find enclosed our new Protocol for the Management of Primary Care Clinical Information for all Patients admitted to acute inpatient services for your information.”

Source location

Response from Sussex Partnership NHS Foundation Trust
Page 2 · response
Published 23 February 2024

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

Operate a system requiring primary care records for new acute admissions within 48 hours, verifying requests and uploading records to Carenotes.

Verbatim wording from the response

“In relation to the timely requests for primary care records and information about our patients, I am pleased to say a new system has been introduced. The new system, now in use is as follows; The Crisis Resolution and Home Treatment Team administrators request a copy of the primary care, summary care record, or encounter report, from the GP”

Source location

Response from Sussex Partnership NHS Foundation Trust
Page 1 · response
Published 23 February 2024

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 an opt-out system informing patients that summary care record access will occur by default, subject to stated exceptions.

Verbatim wording from the response

“In addition, ████████ (Chief Pharmacist) produced guidance for staff regarding the importance of obtaining the primary care, summary care record, which was distributed to Trust staff and taken to staff meetings for sharing and discussion. Clinicians in both primary and secondary care can access summary care records using an NHS Smartcard, once they are set up on the national system. Furthermore, the Trust is currently looking to establish an “opt out” system so that patients in contact with our services are informed that summary care record access will occur by default unless they specify that it may not, (unless a best interest decision needs to be made). ████████ (Chief Pharmacist) has confirmed that this guidance is now included in the induction pack for all new junior doctors joining the Trust.”

Source location

Response from Sussex Partnership NHS Foundation Trust
Page 2 · response
Published 23 February 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Include learning from the death in the quarterly quality report for Trust staff and Clinical Commissioning Groups.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2024.

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 learning from the death in the quarterly quality report for Trust staff and Clinical Commissioning Groups.

Verbatim wording from the response

“The learning from Mr Curry’s death has been included in the Trust’s quarterly quality report available to all Trust staff and our Clinical Commissioning Groups.”

Source location

Response from Sussex Partnership NHS Foundation Trust
Page 2 · response
Published 23 February 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026