PFD report

Norah McGLYNN aka Noreen Philomena McGLYNN · Prevention of Future Deaths report

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Issued 11 Jul 2025•Inner North London

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
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
3

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 raised1

  1. Unavailability of rehydration at home
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.2

  1. Action

    Raise community subcutaneous rehydration availability with local NHS partners for review.

    Stated by Mountfield SurgeryStated plannedThe respondent said that this action was planned when they made their response on 17 July 2025.
  2. Action

    Engage PCN 6 to gather views on providing intravenous rehydration therapy at home.

    Stated by Mountfield SurgeryStated plannedThe respondent said that this action was planned when they made their response on 17 July 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    UCR clinicians cannot prescribe IV fluids because prescribing them falls outside their current scope of practice.

    Stated by Central London Community Healthcare NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Unavailability of rehydration at home

Wider context from the report

“I heard at inquest that, even before her anaphylaxis Ms McGlynn was waiting for an ambulance to take her to hospital. This was on the advice of two GPs and with the agreement of her daughter. However, Noreen McGlynn’s family did not want her to go to hospital. They believed that she had a better chance of remaining well out of hospital. (The challenges that hospital admission present to the elderly are very well recognised.) And if she were now dying, family knew that Ms McGlynn would want to die at home. Her living situation was very supportive. She was a widow but she had an excellent full time carer and a loving, extremely engaged family, with her daughter living near by. The reason that family now favoured hospital admission was because Ms McGlynn had become so dehydrated. They recognised that this was life threatening and likely to make her feel unwell. If the rapid response team from the Central London Community Healthcare NHS Trust who visited, or the GPs from Mountfield Surgery, had been able to offer rehydration at home, this would have been a far preferable course of action for Noreen McGlynn and for her loved ones. Could such rehydration at home have been offered? Could it be offered to others in the future? ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Raise community subcutaneous rehydration availability with local NHS partners for review.

Verbatim wording from the response

“We therefore respectfully submit that IV rehydration is not clinically appropriate or safe to administer at home. We will, however, raise this matter with our local NHS partners to review whether community subcutaneous rehydration pathways could be more widely available, in order to provide alternatives for patients who wish to avoid hospital admission.”

Source location

Response from Mountfield Surgery
Page 3 · response
Published 17 July 2025

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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

Engage PCN 6 to gather views on providing intravenous rehydration therapy at home.

Verbatim wording from the response

“We will also be engaging with our local Primary Care Network (PCN 6) to gather their views on providing rehydration IV therapy at home.”

Source location

Response from Mountfield Surgery
Page 3 · response
Published 17 July 2025

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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

UCR clinicians cannot prescribe IV fluids because prescribing them falls outside their current scope of practice.

Verbatim wording from the response

“The current service specification commissioned by Barnet Clinical Commissioning Group for Urgent Community Response (UCR) services does include the administration of IV fluids. It states that treatment at home may be appropriate for serious illnesses when it aligns with the patient’s preferences. Although this is included in the service specification, decisions around commencing IV fluid infusion need to be made with the clear understanding that the diagnostic and support services available in the community may not match those provided in a hospital setting, including considerations of the need for continuous observations during infusion. For IV fluids to be initiated a medical doctor would need to prescribe the fluids and equipment (whilst UCR clinicians may be non-medical prescribers, prescribing IV fluids falls outside of their current scope of practice).”

Source location

Response from Central London Community Healthcare NHS Trust
Page 2 · response
Published 17 July 2025

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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

Patients requiring IV rehydration or showing physical deterioration are generally conveyed to hospital under the existing deteriorating patient procedure.

Verbatim wording from the response

“Typically, patients requiring IV rehydration or showing any signs of physical deterioration are conveyed to A&E or secondary care for its administration. This approach is also in accordance with our deteriorating patient procedure which states that if a patient’s condition is causing concern, then action needs to be taken either through an assessment by a doctor, appropriately qualified senior clinician, advanced practitioner or the patient should be transferred to A&E or secondary care for further care.”

Source location

Response from Central London Community Healthcare NHS Trust
Page 2 · response
Published 17 July 2025

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

A medical doctor, such as the SPOA doctor or GP, must decide whether IV fluids are needed and prescribe them.

Verbatim wording from the response

“The current service specification commissioned by Barnet Clinical Commissioning Group for Urgent Community Response (UCR) services does include the administration of IV fluids. It states that treatment at home may be appropriate for serious illnesses when it aligns with the patient’s preferences. Although this is included in the service specification, decisions around commencing IV fluid infusion need to be made with the clear understanding that the diagnostic and support services available in the community may not match those provided in a hospital setting, including considerations of the need for continuous observations during infusion. For IV fluids to be initiated a medical doctor would need to prescribe the fluids and equipment (whilst UCR clinicians may be non-medical prescribers, prescribing IV fluids falls outside of their current scope of practice).”

Source location

Response from Central London Community Healthcare NHS Trust
Page 2 · response
Published 17 July 2025

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

Primary care cannot provide home IV rehydration because community clinicians lack the required resources, equipment, staffing and pathway.

Verbatim wording from the response

“GPs and community-based clinicians do not have the resources, equipment, or staffing to deliver and monitor IV therapy at home.”

Source location

Response from Mountfield Surgery
Page 2 · response
Published 17 July 2025

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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

Home IV rehydration is considered clinically inappropriate and unsafe because continuous monitoring requires a hospital or equivalent acute setting.

Verbatim wording from the response

“IV rehydration requires continuous monitoring for complications such as fluid overload, electrolyte imbalance, and infection.”

Source location

Response from Mountfield Surgery
Page 2 · response
Published 17 July 2025

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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

    Continue providing patients and families with clear explanations of available options in similar situations.

    Stated by Mountfield SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025.

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 providing patients and families with clear explanations of available options in similar situations.

Verbatim wording from the response

“We thank you for bringing this important matter to our attention and will continue to ensure our patients and their families are supported with clear explanations of available options in similar situations.”

Source location

Response from Mountfield Surgery
Page 3 · response
Published 17 July 2025

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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