PFD report

Marina Fagan · Prevention of Future Deaths report

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Issued 22 Apr 2016•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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

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. Insufficient availability of specialist neurological care
    Part of recurring concern: Insufficient medical staffing capacity for timely patient carePart of recurring concern: Insufficient neurology service capacity for timely specialist assessment
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Barts Health NHS Trust is responsible for addressing local neurologist availability and staffing levels.

    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 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

Insufficient availability of specialist neurological care

Wider context from the report

“This witness set out his concern that, nationwide, there are insufficient neurologists to provide necessary specialist care. He noted that in the out of hours setting, although there were neurologists available the nearby tertiary care hospital, none were on-call in the hospital to which Ms Fagan was initially admitted. Ms Fagan's general practitioner set out that the current waiting time to see a neurologist in the outpatient setting, is 72 days. Given the issues regarding availability of specialist neurological care, I am concerned that future deaths will occur in similar circumstances. ”

Is this part of a recurring concern?

Yes — Insufficient medical staffing capacity for timely patient care; Insufficient neurology service capacity for timely specialist assessment.

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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

Barts Health NHS Trust is responsible for addressing local neurologist availability and staffing levels.

Verbatim wording from the response

“It is the responsibility of providers to ensure that they have appropriate staffing levels to meet the needs of their patients. The availability of neurologists locally is therefore for Barts Health NHS Trust to address.”

Source location

2016-0162-Response-by-Department-of-Health
Page 1 · response
Published 22 April 2016

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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

Health Education England is responsible for planning the national neurology workforce and commissioning training places.

Verbatim wording from the response

“On a national basis, Health Education England (HEE) plans the future workforce. HEE has consistently invested in the commissioning of training places in neurology and intends to commission 219 training places in 2016/17, a small rise from 217 in both 2014/15 and 2015/16.”

Source location

2016-0162-Response-by-Department-of-Health
Page 1 · response
Published 22 April 2016

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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

National neurology waiting times meet the operational NHS waiting-time standard, so existing arrangements address the national concern.

Verbatim wording from the response

“Where this is not possible, the NHS should take all reasonable steps to offer a range of suitable alternative providers able to see or treat the patient more quickly than the original provider, if this is what the patient wants and it is clinically appropriate. Commissioners are not obliged to take all reasonable steps to find an alternative provider if the patient does not ask for this. Some patients will wait longer than 18 weeks by choice, for personal or social reasons, or because this is clinically appropriate.”

Source location

2016-0162-Response-by-Department-of-Health
Page 2 · response
Published 22 April 2016

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

  1. 1

    Earlier diagnosis was unlikely to have changed the outcome because the condition was already severe.

    Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Earlier diagnosis was unlikely to have changed the outcome because the condition was already severe.

Verbatim wording from the response

“Posterior Reversible Encephalopathy Syndrome (PRES) is a rare disease, which I understand was first described only in 1996, and differential diagnosis can be difficult. This means that many other common conditions can present with very similar symptoms to PRES. I understand that you heard evidence that in Ms Fagan’s case her condition was so severe that, even had a diagnosis been made earlier, the outcome was unlikely to have been different.”

Source location

2016-0162-Response-by-Department-of-Health
Page 1 · response
Published 22 April 2016

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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