PFD report

Julia Jane MacPherson · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 1 Apr 2018•South 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.

View original report
Concerns
6

Raised in this report

Recipients
4

Named on the report

Responses found
3

Of 4 recipients

Stated actions
10

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised6

  1. Failure to follow NICE guidelines for prescribing off-licence medicines
    Part of recurring concern: Unsafe medication prescribing
  2. Failure to provide timely clinical review following reported deterioration
    Part of recurring concern: Failure to conduct timely, appropriate clinical assessmentsPart of recurring concern: Failure to provide timely clinical care
  3. Failure of hospital staff to regularly read clinical and nursing entries in patient medical records
    Part of recurring concern: Failure to review relevant clinical records before care decisions
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.10

  1. Action

    Continue auditing MDT template use, capacity assessments, and responses to family concerns.

    Stated by Oxleas NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2019.
  2. Action

    Implement an MDT meeting template to record family concerns, review capacity and consent, incorporate multidisciplinary information, and document agreed actions.

    Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2019.
  3. Action

    Set expectations that doctors regularly assess and document informal patients’ capacity and consent during weekly MDT reviews.

    Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 January 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Specific circumstances of Julia MacPherson’s individual care and treatment fall outside the regulator’s remit for comment.

    Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.

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 follow NICE guidelines for prescribing off-licence medicines

Wider context from the report

“(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

Open source report

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 provide timely clinical review following reported deterioration

Wider context from the report

“(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients. ”

Is this part of a recurring concern?

Yes — Failure to conduct timely, appropriate clinical assessments; Failure to provide timely clinical 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of hospital staff to regularly read clinical and nursing entries in patient medical records

Wider context from the report

“(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients. ”

Is this part of a recurring concern?

Yes — Failure to review relevant clinical records before care decisions.

Open source report

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 formally review mental capacity to consent to treatment

Wider context from the report

“(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients. ”

Is this part of a recurring concern?

Yes — Failure to recognise impaired decision-making capacity in care decisions; Inadequate informed-consent processes for medical treatment; Unreliable assessment and recording of patients’ mental capacity.

Open source report

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

Absence of a statutory process for recording informal patients' consent to medication

Wider context from the report

“(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Incomplete or missing records of consent discussions for off-licence mental health medication

Wider context from the report

“(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients. ”

Is this part of a recurring concern?

Yes — Unreliable recording of safety-critical mental health information.

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

Continue auditing MDT template use, capacity assessments, and responses to family concerns.

Verbatim wording from the response

“A recent audit of the use of the MDT template and capacity assessments have shown that it is being used and that views and concerns of families are being addressed. These audits will be carried out on a regular basis to give assurance to the trust.”

Source location

2018-0298-Oxleas-NHS-Foundation-Trust
Page 1 · response
Published 19 January 2019

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

Implement an MDT meeting template to record family concerns, review capacity and consent, incorporate multidisciplinary information, and document agreed actions.

Verbatim wording from the response

“The Trust has developed a Multidisciplinary Team (MDT) meeting template following a quality improvement project to enable every member of the MDT to contribute to the review. There is a section for families, carers and significant people in a service user’s life in which any concerns raised are documented to ensure these are discussed in the meeting and agreed actions to address these outlined.”

Source location

2018-0298-Oxleas-NHS-Foundation-Trust
Page 1 · response
Published 19 January 2019

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

Set expectations that doctors regularly assess and document informal patients’ capacity and consent during weekly MDT reviews.

Verbatim wording from the response

“The Trust will make clear its expectations of all doctors to regularly assess and document capacity and consent to treatment for informal patients. This should be done as part of the weekly MDT review process and where there are concerns about a patient’s capacity to understand the treatment then the patient’s informal status must be reviewed and detention sought. This will ensure that such patients come under the statutory process described above. For patients prescribed off-license medication, the ward pharmacist will review the medications and ensure that all processes: discussion with patient and relatives, on-going capacity assessments and efficacy of treatment and risk/ benefits have been checked and are documented. If there are any concerns these will be shared with the consultant prescribing the medication and their Clinical Director.”

Source location

2018-0298-Oxleas-NHS-Foundation-Trust
Page 2 · response
Published 19 January 2019

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

Send all doctors relevant guidance on prescribing off-license medicines and require them to follow it in practice.

Verbatim wording from the response

“Although NICE does not issue specific guidance for the use of off licence medications, the General Medical Council and various Royal Colleges including the Royal College of Psychiatrists have issued advice for doctors when prescribing outside of license. A letter with the respective guidance will be sent to all doctors reminding them that they must follow these in practice. In addition, an educational meeting will take place before the end of summer to remind doctors of the guidance and ensure that it is being followed in practice. Trust doctors (consultant and non-consultant grade) are expected to include this in their appraisals and reflect on how this has changed their practice.”

Source location

2018-0298-Oxleas-NHS-Foundation-Trust
Page 2 · response
Published 19 January 2019

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

Require ward pharmacists to review off-license medication processes, including discussions, capacity, efficacy, risks and benefits, and share concerns with prescribers and Clinical Directors.

Verbatim wording from the response

“The Trust will make clear its expectations of all doctors to regularly assess and document capacity and consent to treatment for informal patients. This should be done as part of the weekly MDT review process and where there are concerns about a patient’s capacity to understand the treatment then the patient’s informal status must be reviewed and detention sought. This will ensure that such patients come under the statutory process described above. For patients prescribed off-license medication, the ward pharmacist will review the medications and ensure that all processes: discussion with patient and relatives, on-going capacity assessments and efficacy of treatment and risk/ benefits have been checked and are documented. If there are any concerns these will be shared with the consultant prescribing the medication and their Clinical Director.”

Source location

2018-0298-Oxleas-NHS-Foundation-Trust
Page 2 · response
Published 19 January 2019

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

Write to all consultants reiterating expectations to read clinical and nursing notes written by trainees and other staff.

Verbatim wording from the response

“In addition, our Medical Director, Dr Okocha will write to all consultants in the Trust reiterating the expectations that they check and read notes which are written by their trainees and other staff.”

Source location

2018-0298-Oxleas-NHS-Foundation-Trust
Page 2 · response
Published 19 January 2019

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

Require doctors to include off-license prescribing practice in appraisals and reflect on its effect on their practice.

Verbatim wording from the response

“Although NICE does not issue specific guidance for the use of off licence medications, the General Medical Council and various Royal Colleges including the Royal College of Psychiatrists have issued advice for doctors when prescribing outside of license. A letter with the respective guidance will be sent to all doctors reminding them that they must follow these in practice. In addition, an educational meeting will take place before the end of summer to remind doctors of the guidance and ensure that it is being followed in practice. Trust doctors (consultant and non-consultant grade) are expected to include this in their appraisals and reflect on how this has changed their practice.”

Source location

2018-0298-Oxleas-NHS-Foundation-Trust
Page 2 · response
Published 19 January 2019

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

Hold an educational meeting before the end of summer to reinforce off-license prescribing guidance and its application.

Verbatim wording from the response

“Although NICE does not issue specific guidance for the use of off licence medications, the General Medical Council and various Royal Colleges including the Royal College of Psychiatrists have issued advice for doctors when prescribing outside of license. A letter with the respective guidance will be sent to all doctors reminding them that they must follow these in practice. In addition, an educational meeting will take place before the end of summer to remind doctors of the guidance and ensure that it is being followed in practice. Trust doctors (consultant and non-consultant grade) are expected to include this in their appraisals and reflect on how this has changed their practice.”

Source location

2018-0298-Oxleas-NHS-Foundation-Trust
Page 2 · response
Published 19 January 2019

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

Return to inspect Oxleas NHS Foundation Trust and follow up the identified concerns to check that necessary improvements have been made.

Verbatim wording from the response

“We will be returning to inspect Oxleas NHS Foundation Trust later in the year. We intend to follow through some of the areas of concern in more detail. This will be to ensure the trust has learnt from this and made the necessary improvements.”

Source location

2018-0298-Response-by-CQC
Page 2 · response
Published 19 January 2019

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

Conducted a follow-up inspection of Oxleas NHS Foundation Trust’s acute wards to assess whether specific improvements had been made.

Verbatim wording from the response

“Since Julia Jane MacPherson's death in May 2016, we have inspected Oxleas NHS Foundation Trust once. This was a follow up inspection of the acute wards in the Trust, including Norman Ward, in February 2017 to see if some specific improvements had taken place since the comprehensive inspection in April 2016. We also carried out regular visits by our Mental Health Act reviewers, and the last one took place on Norman Ward in March 2017.”

Source location

2018-0298-Response-by-CQC
Page 1 · response
Published 19 January 2019

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

Specific circumstances of Julia MacPherson’s individual care and treatment fall outside the regulator’s remit for comment.

Verbatim wording from the response

“We note our legal responsibility to submit a written response to you, however some of the matters of concern relate to the very specific circumstances of Julia MacPherson's individual care and treatment, so we are unable as a regulator to comment on this.”

Source location

2018-0298-Response-by-CQC
Page 1 · response
Published 19 January 2019

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 inspection concluded that prescribing followed NICE guidance and raised no concerns about managing medicines prescribed outside usual levels.

Verbatim wording from the response

“The inspection in April 2016 looked at 105 medicine administration records and concluded that NICE guidance was being followed when prescribing medicines. We did record that three patients were being prescribed medicines outside of the usual levels, but do not raise any concerns about how that was being managed.”

Source location

2018-0298-Response-by-CQC
Page 2 · response
Published 19 January 2019

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 positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Operational matters arising from the concerns are assigned to Oxleas NHS Foundation Trust.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Operational matters arising from the concerns are assigned to Oxleas NHS Foundation Trust.

Verbatim wording from the response

“Your report raises several areas of concern, most of which are operational matters for the Oxleas NHS Foundation Trust.”

Source location

2018-0298-Response-by-Department-of-Health
Page 1 · response
Published 19 January 2019

Open published response
Back to top

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