PFD report

Donna Kirkland · Prevention of Future Deaths report

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Issued 25 Jul 2014•Coventry

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
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
5

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 raised4

  1. Lack of staff awareness of the alcohol content and ingestion potential of alcohol based hand sanitising gels
  2. Patients’ permitted retention of cups and containers of alcohol based hand sanitising gels in their rooms
  3. Patients’ permitted decanting of alcohol based hand sanitising gels into cups and other containers
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.4

  1. Action

    Review access to and use of alcohol-based hand sanitiser across inpatient units.

    Stated by Coventry and Warwickshire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 July 2014.
  2. Action

    Replace wall-mounted alcohol-based hand-sanitiser dispensers with alcohol-free alternatives.

    Stated by Coventry and Warwickshire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 July 2014.
  3. Action

    Raise staff awareness of risks associated with ingesting alcohol-based hand sanitiser.

    Stated by Coventry and Warwickshire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 July 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The inquest identified no further steps for the Trust to take to reduce the risk of future deaths.

    Stated by Coventry and Warwickshire Partnership NHS TrustNo action considered necessaryThe respondent said that no further action was needed.

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

Lack of staff awareness of the alcohol content and ingestion potential of alcohol based hand sanitising gels

Wider context from the report

“(1) Patients having unlimited access to alcohol based hand sanitising gels; (2) Patients being permitted to decant alcohol based hand sanitising gels into cups and other such containers; (3) Patients being permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms; (4) Lack of awareness amongst staff of alcohol content of alcohol based hand sanitising gels and the potential for such gels to be ingested. ”

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

Patients’ permitted retention of cups and containers of alcohol based hand sanitising gels in their rooms

Wider context from the report

“(1) Patients having unlimited access to alcohol based hand sanitising gels; (2) Patients being permitted to decant alcohol based hand sanitising gels into cups and other such containers; (3) Patients being permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms; (4) Lack of awareness amongst staff of alcohol content of alcohol based hand sanitising gels and the potential for such gels to be ingested. ”

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

Patients’ permitted decanting of alcohol based hand sanitising gels into cups and other containers

Wider context from the report

“(1) Patients having unlimited access to alcohol based hand sanitising gels; (2) Patients being permitted to decant alcohol based hand sanitising gels into cups and other such containers; (3) Patients being permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms; (4) Lack of awareness amongst staff of alcohol content of alcohol based hand sanitising gels and the potential for such gels to be ingested. ”

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

Patients’ unlimited access to alcohol based hand sanitising gels

Wider context from the report

“(1) Patients having unlimited access to alcohol based hand sanitising gels; (2) Patients being permitted to decant alcohol based hand sanitising gels into cups and other such containers; (3) Patients being permitted to keep cups and containers of alcohol based hand sanitising gels in their rooms; (4) Lack of awareness amongst staff of alcohol content of alcohol based hand sanitising gels and the potential for such gels to be ingested. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Review access to and use of alcohol-based hand sanitiser across inpatient units.

Verbatim wording from the response

“At the inquest the questions of access to, and use of, alcogel were explored with a number of witnesses from the Trust. Evidence was heard at the inquest, and accepted by the Coroner, that following Donna’s death the Trust had taken steps proactively to review the access to and use of alcogel across inpatient units and to raise the awareness of its staff of the”

Source location

2014-0341-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust_Redacted
Page 1 · response
Published 25 July 2014

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

Replace wall-mounted alcohol-based hand-sanitiser dispensers with alcohol-free alternatives.

Verbatim wording from the response

“Alcogel is a key part of infection control measures, both at the Coventry and Warwickshire Partnership NHS Trust and nationwide in both NHS and private hospitals. An alcohol-free alternative has recently become available to NHS and NHS institutions. It does have some drawbacks compared to alcogel. Nevertheless, prior to the hearing of the inquest this summer, the Trust had investigated for itself this alternative, and had decided to replace the wall-mounted alcogel dispensers on its premises with this alcohol-free alternative.”

Source location

2014-0341-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust_Redacted
Page 1 · response
Published 25 July 2014

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

Raise staff awareness of risks associated with ingesting alcohol-based hand sanitiser.

Verbatim wording from the response

“At the inquest the questions of access to, and use of, alcogel were explored with a number of witnesses from the Trust. Evidence was heard at the inquest, and accepted by the Coroner, that following Donna’s death the Trust had taken steps proactively to review the access to and use of alcogel across inpatient units and to raise the awareness of its staff of the”

Source location

2014-0341-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust_Redacted
Page 1 · response
Published 25 July 2014

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

Monitor access to and use of alcohol-based hand sanitiser across Trust sites.

Verbatim wording from the response

“The Trust will continue to monitor access to and use of alcogel across its sites.”

Source location

2014-0341-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust_Redacted
Page 2 · response
Published 25 July 2014

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 inquest identified no further steps for the Trust to take to reduce the risk of future deaths.

Verbatim wording from the response

“The inquest did not identify any further steps which Coventry and Warwickshire Partnership NHS Trust might take to reduce the risk of future deaths.”

Source location

2014-0341-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust_Redacted
Page 2 · response
Published 25 July 2014

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

    Continue national oversight of reported incidents and learning from alcohol-based hand-sanitizer ingestion events.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 25 July 2014.

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 national oversight of reported incidents and learning from alcohol-based hand-sanitizer ingestion events.

Verbatim wording from the response

“Although incidents of this nature have been reported nationally, the number has significantly reduced as a result of local risk mitigation measures as described in the guidance above. However, there will of course be continued national oversight of reports and learning from such incidents.”

Source location

2014-0341-Response-by-Department-of-Health
Page 2 · response
Published 25 July 2014

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