Other related deaths
PFD Category
Reports: 783
Areas: 72
Earliest: Aug 2013
Latest: 14 Apr 2026
76% response rate (above 63% average). 34% of classified responses show concrete action taken. Reports fell 26% from 91 (2023) to 67 (2024).
PFD Reports
490 resultsNatalie Young
All Responded
2023-0123
15 Feb 2023
Somerset
Department for Transport
Concerns summary (AI summary)
The absence of regulations for mobility scooter operators regarding vision, cognitive ability, and substance impairment, coupled with no registration requirements, poses significant safety risks, especially to vulnerable pedestrians.
Action Planned
(AI summary)
The Department for Transport reminded retailers to advise customers to show consideration for other pavement users and to undertake training in the use of mobility scooters and is supporting the roll-out of a nationwide certified powered wheelchair and mobility scooter assessment and training scheme through Driving Mobility.
Hannah Warren
All Responded
2023-0055Deceased
13 Feb 2023
Swansea Neath Port Talbot
College of Policing
Home Office
Metropolitan Police Service
+1 more
Concerns summary (AI summary)
There is a national lack of formal guidance and training for correlating missing person risk assessments with vehicle stop priorities, leading to dangerous mismatches and inappropriate response levels.
Noted
(AI summary)
The NPCC and College of Policing state that missing persons APP sets out clear processes and procedures and that current ACT instructions should be followed with an instruction to STOP in similar cases. NPCC will raise the issues apparent in the case through appropriate portfolio areas. The Metropolitan Police Service is developing a training package on ANPR and ACT reports, to be rolled out within 12 months. A new Service Level Agreement will require higher authorisation for ACT reports and nominated contacts for updates. The Home Office acknowledges the concerns and states that the College of Policing sets standards for police investigations, including ACT reports. They have consulted with the College, Metropolitan Police and NPCC and are satisfied that current guidance is in place.
Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd
All Responded
2023-0085Deceased
8 Feb 2023
Plymouth, Torbay and South Devon
Approved Clubs
self-governing schools
Chief Constables
+5 more
Concerns summary (AI summary)
Concerns were raised regarding the risks associated with the legal availability, lethality, ease of use, and rapid fire capabilities of certain items, and their role in crime.
Disputed
(AI summary)
Merseyside Police firearms enquiry officers have completed the South Yorkshire Police training package and are enrolled on Mowbray Partners online training. They will also review cases within one month where firearms were seized or surrendered but subsequently returned, and applications refused/licenses revoked but later granted, aiming to complete this by 2nd October 2023. Avon and Somerset Police completed a review and found no cases where approval should not have been granted. They are reviewing their training requirements and will be implementing additional mandatory training for all staff, including PiP Level 1 training. Dorset Police will provide additional training to further enhance the quality of FEO investigations through the national Professionalising Investigations Programme at level 1 over the next 18 months. A presentation of the key learning from the incident to a CPD event for all Firearms Licensing Managers will be delivered in May 2023. North Wales Police will review cases over the last 5 years where applications have been refused or licenses revoked, but where subsequent applications or appeals resulted in a grant, aiming to complete this by 2nd October 2023. They highlight existing processes for quality control and previous review work undertaken. South Wales Police is reviewing approximately 1300 records where certificate holders were subject to a suitability review to determine if certificates were seized, surrendered, revoked or refused and subsequently approved. They are also working with Gwent Police to align processes, conduct peer reviews, and arrange an annual peer assessment of firearms licensing approvals. North Yorkshire Police has established a Gold group to oversee their response and commenced a review of records relating to certificates seized, refused, revoked, or surrendered and then subsequently approved over the last 5 years, aiming for completion by October 2nd. They are developing an Action Plan to manage the response and record decisions. Lancashire Constabulary has commenced a review of all certificates refused, revoked, seized or surrendered and then subsequently approved over the past 5 years, against the March 2023 Home Office Statutory Guidance, expected to be completed by the end of October 2023. They have also introduced process and scrutiny changes, including a dedicated Chief Inspector responsible for Firearms Licensing and training for staff. Greater Manchester Police will review between 70-80 cases at Senior Officer Panel, for the five-year period, where certificates have been seized, refused, revoked or surrendered and then subsequently approved and guns returned. The Firearms Licensing Manager and Detective Sergeant will attend a two-day continuous professional development (CPD) event delivered by Chief Constable Tedds at the College of Policing on the 18th and 19th May 2023. The College of Policing is developing significantly revised and updated Authorised Professional Practice (APP) on firearms licensing. This will underpin the development of a national training course for staff involved in firearms licensing. Surrey Police will review firearms and shotgun licensing prioritizing cases where firearms have been seized or surrendered and then returned; it will review most recent decisions first and applications that have been refused or licences revoked but where subsequent applications/appeals resulted in a grant. An additional resource has been seconded into the department to expedite this review and provide a full report by 2nd October 2023. Norfolk Constabulary will commission external training for Firearms Licensing Unit staff starting in May 2023. They will also conduct a review of certificates seized, refused, revoked, or surrendered and then subsequently approved, prioritizing cases not already subject to renewal, with a dip-sample approach to other cases. Gloucestershire Constabulary will conduct a review of firearms licensing decisions, as per the letter from the NPCC lead, with a target completion date of 2 October 2023. Essex Police is reviewing decisions to return firearms licenses over a five-year period, prioritizing cases where firearms were seized or surrendered and then returned. They have implemented local training for firearms licensing staff, including a lesson plan developed collaboratively with Kent Police, and external auditors will review the team's compliance. Bedfordshire Cambridgeshire and Hertfordshire Police have instructed a review of firearms seized and returned, certificate holders refused or revoked then successfully reapplied, and holders subject to police intelligence reports over the last five years. New role-specific training is being undertaken by all Firearms Explosives Licencing Unit staff, and an external training package has been purchased. West Mercia Police will review firearms licensing decisions related to returns, refusals, revocations, and surrenders over the past five years, aiming to complete the review by the end of October. A designated team, including a firearms instructor and tactical advisor, will conduct the review. Sussex Police's Firearms and Explosives Licencing Unit believes its process for the return of a certificate is suitably stringent and is catered for within a force policy; the team is working with the national NPCC lead and the College of Policing in developing a national curriculum and learning outcomes for Firearms Enquiry Officers, and will be active participants at the two day CPD event hosted by the College of Policing in May 2023. Kent Police will review 134 firearms licensing cases where certificates were returned after seizure/surrender, or granted after refusal/revocation, assessing them against the current Home Office Statutory Guidance. Local firearms licensing training, including refresher courses and mentoring, is provided, with plans to develop a lesson plan with Essex Police by the end of August 2023. City of London Police acknowledge the findings and learnings from the Keyham Inquest and will review their SOP to ensure procedures for Application / Annual Renewal / Return meet or exceed common national standards, including robust checks across medical, crime recording and Risk Assessment. Risk assessment training and CPD training for all licensing team will be implemented on an annual cycle. Devon and Cornwall Police invested £3 million into the force's Firearms and Explosives Licensing Unit (FELU). In 2023, training is planned, including integrating firearms licensing into practical scenarios for Personal Safety Training and presenting key learning from the incident at CPD events. The Lord Chief Justice acknowledges the concerns but states that the report does not substantiate the suggestion that judges are not giving appeals the necessary careful and detailed consideration, are applying the incorrect legal test, or are failing to have regard to the statutory guidance. Nottinghamshire Police has identified a dedicated resource to review firearms licensing cases where firearms were seized/surrendered and later returned, or where licenses were refused/revoked and later granted. A sample of cases from a 2021 review will be independently re-reviewed, and all reviews will be completed by 2 October 2023. Durham Constabulary details their history of firearms licensing reform following a 2013 report and states that they are satisfied that their review of decisions to return firearms to licence holders after seizure or surrender was appropriate and subjected to the appropriate level of scrutiny and oversight. Staffordshire Police and West Midlands Police (collaborated service) provided tables that outline certificates seized and returned, revoked, and refused. They have a series of scheduled quality assurance programmes in relation to internal and external audits over decision making. Northamptonshire Police will prioritise reviewing cases where firearms have been seized/surrendered and then returned, and cases where applications were refused/licenses revoked but later granted, completing this by 2nd October 2023. They have secured temporary resources and engaged external companies to audit the unit. Leicestershire Police will review cases from April 2023 for the past 5 years where certificates were seized, refused, revoked or surrendered and then subsequently approved, prioritizing cases where firearms were seized or surrendered. The review will be conducted by individuals independent from the original decision makers and findings will be reported to the strategic lead for Firearms Licensing. The Metropolitan Police expresses condolences and describes existing processes for reviewing firearms licensing decisions, including reviews conducted in August 2021, and states they are contributing to national discussions on firearms licensing training. They explain the process used to identify cases for review following the Home Secretary's request. Staffordshire Police (and West Midlands Police, as part of a collaborated service) detail existing training for staff, including the National Triage Firearms Classification Course and Police National Decision Model training. They also refer to the review of certificates seized, refused, revoked or surrendered and subsequently approved. The Home Office is allocating £500,000 to the College of Policing to develop accredited training for firearms licensing staff. They will consult on mandating this training and are working to address health information sharing, in consultation with medical bodies. Thames Valley Police will review seized and returned guns over a 5-year period, grants that have been revoked/refused/surrendered, and applications refused/revoked but subsequently granted via appeal. The aim is to complete these stages by 2 October 2023. Devon and Cornwall Police completed a review of 611 license holders identified as meeting the criteria of having certificates seized, refused, revoked or surrendered and then subsequently approved between May 2018 and December 2019. Eleven of these cases identified internal processes that did not meet expected standards, but no ongoing risks were identified. Warwickshire Police states that they have already responded to the Home Secretary's request in 2021 regarding license applications that were refused or revoked but subsequently granted. The force will direct a review of firearms and shotgun licensing, prioritizing cases where firearms were seized or surrendered but then returned. Suffolk Constabulary will review cases relating to certificates issued between April 2019 and August 2020. For other periods, they will dip-sample cases, with a wider review if concerns are identified, and highlight prior review work undertaken in Autumn 2021. Dyfed Powys Police will undertake a further review of decision files where firearms have been seized following any incident and subsequently returned to the holder. They welcome and support the recommendation of the Coroner to formalise a training programme to encompass all Firearms roles and responsibilities. Derbyshire Police has implemented IT system improvements for recording and sharing information, ensuring automatic notifications to the firearms licensing team for incidents involving license holders. They are developing a digital learning package for frontline officers and are exploring an independent scrutiny panel.
Kirsty McKie
All Responded
2023-0043Deceased
4 Feb 2023
Manchester South
Foreign Secretary
Concerns summary (AI summary)
There is low awareness among UK travellers of methanol poisoning risk from counterfeit alcohol abroad, exacerbated by insufficient government publicity compared to other nations.
Action Planned
(AI summary)
The British Consulate in Bali will place an information banner about methanol poisoning risks in the international arrival area of the local airport from June to December, and the FCDO will engage with the UK Travel Industry and Student Brand Ambassadors to raise awareness.
Andrew Bowles
All Responded
2023-0423
31 Jan 2023
Birmingham and Solihull
Birmingham and Solihull Mental Health N…
Sandwell and West Birmingham NHS Trust
Concerns summary (AI summary)
A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap that compromised the patient's assessment and could risk other patients' lives.
Action Planned
(AI summary)
The two Trusts have agreed to allocate access to hospital records for bank staff who regularly work shifts within the Psychiatric Liaison Team to improve information sharing. Issues will be monitored through clinical governance at BSMHFT.
Joseph Price
All Responded
2023-0019Deceased
19 Jan 2023
County Durham and Darlington
NHS England
Concerns summary (AI summary)
Prison healthcare failed to routinely inquire about and record family history of sudden cardiac death during reception health screenings, missing opportunities to identify and screen at-risk inmates.
Action Planned
(AI summary)
NHS England acknowledges the concerns and is refreshing the secondary health screening template to include a specific prompt for users to ask relevant questions relating to family history. All reports received are discussed by the Regulation 28 Working Group to ensure that key learnings are shared across the NHS.
Leroy Hamilton
All Responded
2023-0013Deceased
11 Jan 2023
Birmingham and Solihull
Birmingham and Solihull Integrated Care…
Birmingham and Solihull Mental Health N…
Department of Health and Social Care
+2 more
Concerns summary (AI summary)
Critical shortages of inpatient mental health beds and PDU spaces leave acutely ill patients without specialist care. Police also failed to correctly classify and risk-assess mentally unwell individuals as high-risk missing persons.
Action Planned
(AI summary)
West Midlands Police have taken multiple steps including updating missing person investigation training, providing a toolkit for staff interactions with missing persons, upgrading the missing persons recording system, and developing training in partnership with Birmingham and Solihull Mental Health Foundation Trust. Birmingham and Solihull ICB, with BSMHFT and UHBFT, are jointly reviewing pathways of care for acutely unwell people requiring mental health support, including the need for increased mental health beds and Psychiatric Decision Unit spaces. A consistent system-wide protocol across urgent care services for mental health patients who go missing will be led by the Mental Health Provider Collaborative. The Department of Health is supporting the NHS to reduce waiting times in A&E by adding beds, speeding up discharge, and increasing transparency. West Midlands Police are setting up a working group with key partner agencies to discuss and design a joint missing person protocol.
Floyd Carruthers
All Responded
2023-0006Deceased
5 Jan 2023
Birmingham and Solihull
Minister of State, HM Prison and Probat…
Concerns summary (AI summary)
Prison staff lacked adequate training on implementing safeguarding policies for self-neglect, and existing escalation routes focused on violence/self-harm, creating a gap in addressing non-violent injurious activity.
Action Taken
(AI summary)
HMP Birmingham issued a notice to staff about safeguarding and the need to take action when prisoners neglect their welfare. Safeguarding is now a standing item at weekly briefings, and trainers will emphasize self-neglect; a HMPPS training program on safeguarding will be available from December 2023. A learning bulletin will remind staff to identify and refer prisoners who appear to be self-neglecting.
Sylvia Price
All Responded
2023-0009Deceased
4 Jan 2023
Suffolk
Minister of State for Disabled People, …
Concerns summary (AI summary)
The lack of enforceable requirements for clear signage identifying accessible toilet facilities in public buildings, despite its absence contributing to a death, poses a risk for future accidents.
Action Planned
(AI summary)
The Department for Levelling Up, Housing and Communities is updating Building Regulations regarding toilet provision and preparing statutory guidance in a new Approved Document. They will hold a period of public consultation to supplement evidence already held by the department.
Emma Powell
All Responded
2022-0416Deceased
28 Dec 2022
North Wales (East and Central)
Prime Minister’s Office
Tesco PLC
Concerns summary (AI summary)
Retailers fail to provide essential safety advice at the point of paddleboard sale, specifically regarding the mandatory wearing of life-saving equipment and appropriate leash usage for varying water conditions.
Action Planned
(AI summary)
Tesco will add a sticker to the front of their paddleboard packaging with safety information and a QR code linking to British Canoeing's website, and will share information with other retailers via the British Retail Consortium's Product Safety Committee. They have made arrangements for stores to receive and affix the stickers to units delivered in 2022. The Department for Business and Trade has referred the report to Hertfordshire Trading Standards, asked the Office for Product Safety and Standards (OPSS) to write to the British Retail Consortium and major retailers, liaise with enforcement partners and manufacturers, and write to the British Standards Institute to consider industry standards relating to paddleboards.
Allah Ismail
All Responded
2022-0411Deceased
22 Dec 2022
Manchester City
British Thoracic Society
Healthcare Quality Improvement Partners…
Concerns summary (AI summary)
Concerns highlight the need for a national audit of emergency oxygen delivery, updated guidelines for trauma patients and air travel with respiratory conditions, and better use of audit tools by NHS Trusts.
Action Planned
(AI summary)
The British Thoracic Society (BTS) has confirmed that HQIP would support an application for inclusion in the Quality Accounts Audit list, relating to a recurrent national audit of emergency oxygen. The BTS suggests that the CAA address the gap in guidance regarding trauma patients in any further revision of its guidance. The Civil Aviation Authority (CAA) has amended its guidance to include new information that is relevant to passenger fitness to fly, which reflects the recommendation in the Report, under the section entitled: ‘Surgical Conditions - Trauma’ and will discuss the content of the Report at the next UK Fitness to Fly Forum meeting on 5th September 2023.
Akeem Rhoden
All Responded
2022-0414Deceased
13 Dec 2022
South Wales Central
Brecon Beacons National Park Authority,…
Concerns summary (AI summary)
Waterfall signage is inadequate, poorly placed, and lacks clear, concise warnings about water dangers, particularly for non-swimmers, contributing to a lack of awareness of potential drowning risks.
Action Planned
(AI summary)
Natural Resources Wales is commissioning a report from an independent expert concerning visitor safety management including signage in Waterfall Country. Pending the report, semi-permanent signs are being erected at various locations in Waterfall Country. The council acknowledges concerns and will consider signage at the site, undertaking a signage review and implementing necessary actions. The Neath Port Talbot website has been updated to advise individuals of potential risks involved and signs will be erected to advise individuals of unpredictable water flow.
Melsadie Parris
All Responded
2022-0390
2 Dec 2022
Buckinghamshire
Buckingham Council Children’s Services
Concerns summary (AI summary)
Social work failed to conduct renewed home visits or liaise with mental health teams regarding a carer's admitted psychosis, relying on old assessments and missing critical information about the carer's deteriorating mental state.
Noted
(AI summary)
Buckinghamshire Children's Social Care acknowledges the coroner's concerns regarding a comment made by a carer. They note the coroner's finding that the child was not at risk at the time and state that without new evidence, they would have no legal right to insist on a further visit.
Celia Marsh
All Responded
2022-0379
21 Nov 2022
Avon
British Hospitality
British Retail Consortium
British Society for Allergy and Clinica…
+5 more
Concerns summary (AI summary)
The investigation of suspected anaphylaxis deaths is hampered by outdated pathology guidance, poor sample retention, delayed reporting, and insufficient education for medical staff and high-risk patients. There's also a lack of robust systems to capture anaphylaxis cases.
Noted
(AI summary)
The UK Health Security Agency states that responsibility for establishing systems related to food policy and anaphylaxis sits outside of their remit, and instead lies with the Food Standards Agency and the Health and Safety Executive. UKHospitality commits to carrying out a consultation with members on managing the risk of vegan dishes for people with hypersensitivity, and reflecting any recommendations in future updates to the Industry Guidance. The Food and Drink Federation highlights existing guidance on allergen labelling, particularly regarding the differences between 'free-from' and vegan claims and will continue to support the work of the FSA. The Food Standards Agency will focus on a smaller subset of priorities including Precautionary Allergen Labelling (PAL), improving information in the non-prepacked sector, and enabling a step-change in the knowledge, skills, and food safety culture of staff in the 'non-prepacked' sector through training. The British Retail Consortium supports members with label decisions but emphasizes company responsibility, noting challenges with 'free-from' and vegan definitions and the potential for unintended consequences with specific dietary statements. The British Society for Allergy and Clinical Immunology will consider holding an educational event on food avoidance in relation to adults with eczema and will address the need for improved recording and analysis of anaphylaxis fatalities. The Department of Health and Social Care acknowledges the recommendation to establish a robust system of capturing and recording cases of food-related anaphylaxis and notes that data regarding all anaphylaxis-related deaths in England and Wales are documented by the Office for National Statistics and the British Society for Allergy and Clinical Immunology also holds a register. The Royal College of Pathologists is updating its autopsy practice guidelines for suspected acute anaphylaxis to include contact details for the UKFAR and direct pathologists to report fatal anaphylaxis cases.
Awaab Ishak
All Responded
2022-0365
16 Nov 2022
Manchester North
Department of Health and Social Care
Ministry of Housing, Communities & Loca…
Concerns summary (AI summary)
The provided text refers to a Housing Ombudsman report but does not detail specific coroner's concerns.
Noted
(AI summary)
The Secretary of State calls on social housing providers to treat damp and mould seriously, meet the Decent Homes Standard, and self-refer to the Regulator of Social Housing if in breach of standards. They also highlight the upcoming Social Housing Regulation Bill to hold landlords accountable. The Secretary of State requests local authorities prioritize improving housing conditions for private and social tenants, focusing on damp and mould. They request information on the number of properties with damp and mould and how enforcement of housing standards is being prioritized. The Secretary of State asks legal representatives to direct social housing tenants with concerns about housing to the Social Housing Ombudsman, highlighting recent changes making it easier to access the Ombudsman. The government outlines actions taken to address damp and mould in social housing, including issuing guidance to landlords, suspending funding to Rochdale Boroughwide Housing, and awarding funding to areas with poor privately rented homes. They also highlight the Social Housing Regulation Bill to hold landlords accountable.
Graham Flindle
All Responded
2022-0349
4 Nov 2022
Manchester South
Greater Manchester Health and Social Ca…
Concerns summary (AI summary)
Community health professionals lacked widespread understanding of FIT test effectiveness for early bowel cancer detection. GPs also struggled to identify critical haemoglobin test results amidst high volumes, highlighting a need for better prompts and education.
Action Planned
(AI summary)
Greater Manchester Integrated Care's Cancer Alliance recirculated a webinar and resources on cancer and anemia to primary care clinicians and is developing clinical decision support tools for GPs to "think cancer" when certain codes are entered. Learning will be presented/shared with the Greater Manchester System Quality Group and cascaded to professionals through relevant governance and learning forums.
John Fallon
All Responded
2022-0348
4 Nov 2022
Manchester South
Greater Manchester Health and Social Ca…
Concerns summary (AI summary)
Care homes lack routine speech and language therapy assessments for denture changes, leading to unsuitable diets and increased choking risk due to delayed dental services. Furthermore, care homes do not routinely have suction machines for choking emergencies.
Action Planned
(AI summary)
NHS Greater Manchester Integrated Care will share learning from this case with the Greater Manchester System Quality Group and cascade it to professionals through relevant governance and learning forums. The Team are currently looking into any additional training in relation to obstructed airways that can be undertaken by care home staff.
Keith Dimond
All Responded
2022-0338
22 Oct 2022
North East Kent
East Kent Hospitals University NHS Foun…
Concerns summary (AI summary)
Significant communication failures led to treating clinicians being unaware of a previous aneurysm diagnosis, resulting in inappropriate treatment. Additionally, patients were discharged on anticoagulants without adequate risk advice, and specialist recommendations were disregarded.
Action Taken
(AI summary)
East Kent Hospitals University has taken several steps including improving digital record accessibility, emphasizing the importance of clinical history and previous conditions, improving communication regarding patient status and treatment decisions, and providing additional training on Careflow usage.
Ruwaida Adan
All Responded
2022-0336
22 Oct 2022
East London
Capital Karts Trading Ltd
Concerns summary (AI summary)
The report raises concerns about the reliance on reception checks for go-kart clothing and hair, noting track marshals frequently miss loose items, and there is a lack of changes to training and monitoring of track marshals.
Action Taken
(AI summary)
Capital Karts implemented enhanced safety measures following the incident, including providing safety information at booking, reiterating warnings at reception, and ensuring staff check for loose clothing before customers enter the venue.
Robert Evans
All Responded
2022-0322
18 Oct 2022
Swansea and Neath Port Talbot
HMP Swansea
Concerns summary (AI summary)
HMP Swansea has a repeated history of self-inflicted deaths soon after arrival. Critical witness accounts were not immediately captured after a death, hindering investigations and preventing lessons from being learned.
Action Planned
(AI summary)
HM Prison and Probation Services is drafting a new HMPPS Policy Framework, updating the policy for prisons to follow in the event of a death in custody, including guidance to ensure that staff who have relevant information are identified and prompted to make a record of this at an early stage.
Carl Wright
All Responded
2022-0324
17 Oct 2022
Nottinghamshire and Nottingham
Nottingham University Hospital NHS Trust
Concerns summary (AI summary)
Inexperienced junior doctors handled patient care and deterioration assessments without senior input, and blood test results were not reviewed promptly, risking patient safety.
Action Taken
(AI summary)
Nottingham University Hospital has taken immediate actions, including a Consultant from Linden Lodge physically assessing patients transferred there, and developing a specialty referral guidance and a Standard Operating Procedure (SOP) to review all requested tests for patients daily with documentation.
Oli Hoque
All Responded
2022-0316
13 Oct 2022
East London
Department of Health and Social Care
Concerns summary (AI summary)
The MHRA's inability to compel timely clinical data hinders robust safety investigations into potential vaccine adverse events, impacting public interest in drug safety.
Action Taken
(AI summary)
The MHRA has worked with the NHS to enable interoperability and connectivity of reporting systems, such as the new Learning from Patient Safety Events System (LPSE) to allow automatic electronic upload into MHRA databases. The MHRA also continues to educate and promote the Yellow Card scheme with healthcare professionals.
Reginald Cauthery
All Responded
2022-0326
4 Oct 2022
Inner North London
CECOPS
Care Quality Commission
Department of Health and Social Care
+3 more
Concerns summary (AI summary)
A vulnerable person's telecare service was not reviewed despite increased fire risk, and smoke alarms were not connected to telecare, delaying emergency fire brigade notification.
Noted
(AI summary)
The TEC Services Association (TSA) will issue guidance to certified monitoring organizations by the end of November 2022. They also plan to develop a Fire Call Handling Pathway Decision Support Tool with the support of NFCC and LFB, but anticipate it will not be available until 2024. The CQC acknowledges the concerns but states they relate to services outside their scope of regulation (fire service and telecare service) and therefore they have no powers to prevent future deaths in relation to these services. The Department of Health and Social Care has reminded local authorities to consider technology-enabled care in maintaining independence and linking preventative devices like smoke detectors. It also published an updated Adult Social Care Digital Skills Framework to support the development of digital skills across the adult social care workforce. The organisation recommends monitored smoke detectors and rapid heat detectors for elderly and vulnerable service users, referencing recommendations made with London Fire Brigade in 2003. The London Borough of Hackney will address its procedures and guidance within its 'Mosaic' system to reduce risks to vulnerable individuals, especially regarding fire safety for those with risk factors like being bed-bound and a smoker; a table detailing planned actions and timelines is attached. The Home Office will share information from the case with the National Fire Chiefs Council (NFCC) and encourage them to disseminate findings and highlight the importance of linking telecare systems to smoke alarms during fire safety checks.
George Elliott
All Responded
2022-0309
4 Oct 2022
Avon
North Bristol NHS Trust
Concerns summary (AI summary)
The patient safety investigation overlooked obvious failings in falls risk assessment and management, including inadequate assessment and missed re-assessments, resulting in lost learning opportunities and compromised patient safety.
Action Taken
(AI summary)
The Trust acknowledges shortcomings in the investigation report regarding Mr. Elliot's fall and states that the Falls Policy referenced has been replaced with an updated policy in December 2021. They are conducting a gap analysis using the PSIRF national guidance to improve investigation processes, and findings will be reported through relevant committees.
Khalid Yousef
All Responded
2022-0193
Birmingham and Solihull
NHS England, Birmingham and Solihull Me…
Concerns summary (AI summary)
Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This is compounded by misunderstanding of L&D's role and a reduction in qualified Forensic Medical Examiners.
Noted
(AI summary)
NHS England clarifies that Liaison and Diversion services do not directly commission psychiatrists but are for referral. They are developing a new service specification to clarify expectations for access to psychiatry and are reviewing the L&D career and competency framework. NHS England clarifies that while the Liaison & Diversion service model does not directly commission psychiatrists, access can be arranged via urgent referral. They state that a Career and Competency Framework for L&D services, published in 2018, is currently under review, and regional commissioners will consider it for workforce and quality issues. West Midlands Police will create a formal escalation process for custody staff regarding Liaison & Diversion decisions, review mental health training for custody officers/staff, and provide clear advice on the L&D function within six months. West Midlands Police will create a formal escalation process for custody staff disputing Liaison and Diversion decisions, review mental health training for custody officers, and provide clear advice to frontline staff on the L&D function. These actions are planned within six months. Birmingham and Solihull Mental Health Trust plans to discuss liaison clarity with West Midlands Police, develop internal communications about the L&D team's role, and review/update the L&D induction programme and introduce reflective practice groups with psychologists by October 2022. Birmingham and Solihull Mental Health Trust plans to discuss liaison clarity with West Midlands Police, develop internal communications about the L&D team's role, and review/update the L&D induction programme and introduce reflective practice groups with psychologists by October 2022. NHS England clarifies that the Police Custody Healthcare Service (PCHS) policy and commissioning responsibilities lie with the Home Office and Police and Crime Commissioners (PCCs) respectively, not NHS England. They state their role is advisory, and they will continue to work collaboratively with the National Police Chiefs Council (NPCC) to align PCHS and Liaison & Diversion service specifications. The Home Office clarifies that commissioning for L&D services is for NHS England and police custody healthcare services for PCCs, and it is not their place to intervene. However, Home Office officials are working with the NPCC, NHS England, and DHSC to improve escalation processes and mental health management in custody, with a view to the NPCC issuing new guidance.