Matters of concern:

• It was accepted in evidence that neither the doctor who escorted the wrong patient from the Emergency Department to radiology, nor the radiographer who undertook the CT scan on her, checked the identity of the patient in question. No transfer checklist was completed, and the patient was not asked to complete and/or sign the CT scanning questionnaire herself. No member of staff inquired as to the outcome of this patient’s CT scan prior to her discharge a few hours later.
• The scanning error was recognised by a radiologist on the 15th of October 2024, but was not conveyed to Mrs Honeybone’s treating team until late October, by which time she had died and her death had been scrutinised by the Medical Examiner and certified by her treating doctor as wholly natural and not requiring referral to the Coroner.
• As a result of the aforementioned delay, a Trust investigation did not commence until late November 2024. No prompt after action review therefore occurred in the hours and days after the error was recognised. When the Trust investigation did commence, staff directly involved either could not be identified or had no recollection of events.
• Despite hearing evidence that it was a doctor who would have escorted the wrong patient to scanning, the Trust Investigation focussed on nursing involvement with the patients in question and did not seek to identify and question medical team members.
• An Action Plan was drawn up as a result of the Trust Investigation, but for various reasons no audit of compliance with patient identification processes commenced until early August 2025, some ten months after Mrs Honeybone’s death. The results of the audit thus far were made available to me at inquest and indicate that 1 in 5 audited treatment encounters between staff of all grades and specialisms still occur without the patient being positively identified.
• The coroner heard evidence that while radiology transfer checklists are routinely completed ‘in hours’ at Scarborough Hospital when a dedicated HCA is on duty to perform this task, no such checklist is in use at the Trust’s York site at any time of the day. Mrs Honeybone’s misidentification occurred ‘out of hours’ at Scarborough when no designated person assumes responsibility for this task at that site.
• The coroner considers the above represent a continuing risk to others from misidentification and delayed responses to identified errors, with clear implications for patient safety.

1. Inadequate incident reporting.
2. Failure to appropriately ‘investigate’.
3. Poor quality of learning response/investigation.
4. Shortcomings in record-keeping and disclosure of documentation for inquests.
5. Lack of evidence of organisational learning.

Evidence established that at the time of the first call, Roman was critically unwell, displaying symptoms including bluish lips, but this information was not elicited during triage. Roman was of mixed ethnicity and had a darker skin tone, as his father explained to the call handler. The NHS Pathways question requiring confirmation that the patient was “a deathly colour” was not understood by his father. Clearer prompts—such as asking whether the lips were blue or grey—were not asked. A recommendation made during the subsequent review to amend this NHS Pathways wording was not accepted by those responsible for the system’s content.

 Ambulance availability was severely constrained due to significant delays in hospital handovers, leaving no crews free to respond. On the balance of probabilities, had clearer wording been used and the relevant information obtained, Roman would have been categorised as Category 1, for which an ambulance would be expected to arrive within approximately ten minutes even during surge conditions. While being driven to hospital, Roman suffered a cardiac arrest. His mother moved into the footwell of the passenger side and commenced CPR as they continued their journey.

On arrival at the hospital, the family vehicle was involved in a collision, during which Roman’s mother sustained serious injuries. Roman could not be resuscitated and died shortly after arrival. I also heard evidence that Roman had been using his blue (salbutamol) inhaler more frequently than recommended, indicating poor asthma control, and that neither he nor his family were aware of the clinical significance of this increased use. Following his death, the GP practice conducted a review and introduced measures to better identify and monitor patients with high salbutamol use, including keeping a list of such patients, automatically booking reviews when further inhalers are requested, liaising with community pharmacists, and placing alerts on patient records to support timely assessment. Notwithstanding the Drug Safety Update issued on 25 April 2025 reminding clinicians of the risks associated with increased salbutamol use, the evidence in this case indicates that the importance of excessive reliever use may still not be fully recognised by patients or by primary care.  

Matters of concern

1. Limited awareness of salbutamol overuse Evidence showed that patients and families may not appreciate the clinical significance of increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma. 
2. Identification and follow-up of reliever overuse Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised. 
3. Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand. 
4. Risks when families transport critically unwell patients The absence of an available ambulance for several hours resulted in the family transporting Roman to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency. 
5. Clarity of NHS Pathways triage wording Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information. This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress   

1. Prophylactic antibiotics for severely immunocompromised patients: The inquest heard evidence that patients like Aarav who are immunocompromised require additional prophylactic antibiotics for procedures. This is not covered in the current NICE guidelines. The concern is that there is currently no guidance for the use of prophylactic antibiotics in severely immunocompromised patients. 
2. Experience and competence of trainees: The inquest heard evidence that there was confusion around the experience and level of the trainee involved. He was thought to be an ST6 when he was an ST4. The concern is that there is no mechanism to evidence trainees experience and competence when they travel to various different hospital trusts as part of their training. 
3. Consent forms: The parents of Aarav were unaware that a trainee would be doing the liver biopsy. The concern is that there is currently no way to obtain consent when a trainee will be doing the procedure. 
4. Individual patient risk factors: Aarav had a complex medical background and several risk factors for any procedure. The concern is that there is currently no mechanism to identify individual patient’s risk factors so that all clinicians involved in their care are aware.  
5. Learning from deaths: The initial M&M meeting after Aarav’s death was described as inadequate. The concern is that there was no immediate learning from this tragedy and further consideration is needed to ensure a safe and effective mechanism to properly learn from deaths at the earliest opportunity. 
6. Electronic patient records: Evidence that the lack of electric medical records meant clinicians found it difficult to see all of the patient’s medication details. The concern is that critical information can be missed if clinicians do not have access to all the clinical records when planning treatment. 

Evidence was heard that prior to his attendance in the Accident and Emergency department on the 16 July 2024, Terrence had been seen at home by a paramedic from his surgery, who was concerned by Terrence’s presentation and wanted to admit him to hospital. However, Terrence was reluctant so it was agreed that urgent blood tests would be taken in the first instance.

The results of these tests were seen by a GP, and due to the findings (which indicated a possible serious infection or inflammation) the GP called Terrence and told him to go straight to hospital, and whilst enroute she would speak to the Medical Assessment Unit.

In evidence the GP said she then spent 30 minutes on the telephone trying to contact the Medical Assessment Unit as is the required procedure, to discuss Terrence’s admission.

After being unable to contact the Medical Assessment Unit, the GP contacted Terrence, via a family member, and told him that as she could not contact the Medical Assessment Unit he should head to the Accident and Emergency department instead. The GP told Terrence she would pre- alert the Accident and Emergency department to his arrival.

The GP then spent a further period of time telephoning the Accident and Emergency department but again could not get through.

As such upon arrival, a patient who was considered by their GP to be significantly unwell enough to warrant either admission to the Medical Assessment Unit, or that Accident and Emergency should be pre-alerted to their arrival, was unable to speak to either unit prior to the patient’s arrival.

Terrence endured a 5 hour wait in Accident and Emergency before being seen. Although observations taken at the time of his subsequent admission suggest he had not developed sepsis at this stage, I am concerned that the inability of a GP to be able to promptly communicate with either the Medical Assessment Unit or Accident and Emergency department may lead to future deaths in cases where suspected sepsis or other life threatening conditions have been differentially diagnosed, especially if those conditions have progressed further than Terrence’s had at the time of his arrival.

I am further concerned that evidence was heard from a clinician based at the Ipswich Hospital itself, that they too found contacting the Medical Assessment Unit extremely difficult, with internal hospital telephone calls frequently going unanswered.

Mental health-related deaths examined by coroners arise within complex, evolving multi-sector contexts and do not frequently identify single errors. Minimising such deaths may require coordinated strategies across healthcare, social care and justice systems. Analysis of PFDRs allows identification of patterns that may inform such actions. PFDRs should be analysed routinely and patterns followed over time.

Matters of concern

• Avery’s mother suffered from migraines which were increasing in severity, so she sought advice from her GP when aged 21 years old. She was prescribed Candesartan 4mg by her GP shortly before her 22nd birthday. This was to be taken daily and was placed on a repeat prescription of 28 tablets. The dose was increased to 8mg after 3 months and following a referral, the treatment was endorsed by a Consultant Neurologist at a consultation 4 months after the initial prescription. The evidence revealed that no advice was provided as to the risks of this medication should she be considering having a child. 
• Following a positive pregnancy test in April 2024, Avery’s mother sought advice from her GP about which of her prescribed medications were safe to use during pregnancy. 
• During the telephone consultation with her GP on 11 April 2024 she was given specific advice to avoid using 3 of 6 prescriptions. However the evidence highlighted that Avery’s mother was given only generic advice that it was best to avoid all medication during pregnancy but was not given specific advice to stop using Candesartan, and the risk of continuing to take this medication in pregnancy was not identified during this consultation. 
• Although Avery’s mother had a number of attendances with clinicians throughout her antenatal care, the evidence revealed that she was given no additional advice regarding the safety of her medication and, whilst she was advised to seek advice from her GP as the prescriber, she did not feel it was necessary to do so having already had such a consultation in April 2024. 
• Avery’s mother continued to suffer from migraines during her pregnancy and was unaware of the risk posed by taking Candesartan in pregnancy due to a lack of clear and definitive advice about the risk. I am concerned that she was able to resume taking Candesartan approximately 14 days after her initial GP consultation as the medication remained on a repeat prescription which she was able to continue to request during her pregnancy, and each request was approved without a detailed review. The last repeat prescription being approved only 12 days prior to Avery’s birth. 
• The coroner's concern is that despite advice from the GP that it was best to stop all medication during pregnancy, Candesartan remained as a repeat prescription and, in addition to that, there were no warnings placed on the system which would have alerted the clinician approving the request for the repeat prescription that the patient was pregnant thus necessitating a review. 

• Doulas provide continuity of care and give emotional, informational and practical support throughout pregnancy, labour and after the birth of a baby: those words come from Doula UK’s website. Doula UK is the largest representative body for Doulas, but it is not a regulatory body, it does not represent all doulas, indeed many doulas are not members of Doula UK. Doula UK have put in place membership requirements, training offers and much guidance, but the role of a doula is clearly diffuse in practical terms and capable of multiple understandings not just by doulas but their clients and midwives.
• It appears that doulas have been increasingly used and increasingly offer services – as here – on a paid basis.
• As MNSI (Maternity & Newborn Safety Investigations – formerly HSIB) put it in their report into this birth, “MNSI acknowledges that there is no regulation of doula care or any guidance on how the two services interact with each other. MNSI considers the dynamics of a situation, where a third party are involved can provide additional challenges for staff, such as making clinical recommendations against personal recommendations or views and providing usual care that could be viewed as interference rather than surveillance.”
• MNSI have identified 12 cases in which there was evidence that doulas worked outside of the defined boundaries of their role and in which the care or advice provided by the doula was considered to have potentially had an influence on the poor outcome for the family.
• There was evidence given at the inquest by experienced midwifery professionals highlighting that provision of guidance would be helpful for all involved with a birth at which a doula was present.
• The issues of doula registration, regulation and training are therefore points of concern the coroner would commend for review.

Jen had not made an informed decision to have a home birth and if the out of guidance plan had been completed and all the relevant information provided to her, it is more likely than not she would have given birth in an alternative setting and both Jen and Agnes would have survived.

If the fetal heart rate monitoring had been conducted correctly and every 5 minutes, it was more likely than not an abnormal fetal heart rate would have been noted up to an hour before Agnes was born and an urgent transfer to hospital would have occurred. The coroner found emergency services would have been on scene when Agnes was born and effective resuscitation would have been administered which would likely have prolonged her life. Had this call been made it is more likely than not Jen would have survived as the after care delivered to her would have noted a perineal tear and administered syntemetrine immediately.

The coroner heard evidence that since the deaths, MFT have completely overhauled the home birth service provision. The new service became operational in April 2025. In the six month period within the MFT area of GM they have received requests from 34 women for out of guidance home deliveries. Five of these could not be supported due to safety issues.       

Of the 29 out of guidance home births, 15 (50%) required transfer to hospital for varying degrees of obstetric emergency.

Matter of concerns

1. There is no national guidance in respect of home births. Specifically, robust evidenced based guidance on home birth care, similar to that which is in place for intrapartum care in a hospital setting.
2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care. There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting.
3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service. There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework.
4. Even though there is a very small risk of death, this is not something which is discussed with women particularly in relation to maternal death, even if the woman has a recognised risk such as a post-partum haemorrhage. There is no guidance to ensure the risk of death to both mother and baby is discussed with any woman considering a home birth irrespective of being considered high or low risk.
5. NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only refers to the potential risk of death to a baby. There is no mention in the guidance of risk to the mother.
6. Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads women to consider that pregnancy encompasses all stages through to delivery of a child. Practice does not personalise or individualise risk so women can fully understand what the level of risk is for them in actually being pregnant, or what the level of risk is for them in giving birth.
7. In order to maintain their skills, there is no set number of deliveries a community midwife must conduct following qualification. There is no mandated number of deliveries that any midwife (irrespective of the settings in which they are working) must complete once they have qualified as a midwife in order to maintain their registration. The level of experience of community midwives in conducting deliveries is not information routinely provided to women to inform their decision whether to have a homebirth.
8. No bespoke training needs analysis has been conducted focusing on midwives practicing in home birth teams.
9. The lack of national data collection means there is no data to evidence the number of women who are transferred in during labour or after birth, maternal or neonatal outcomes, number of women who are considered out of guidance.
10. The no national guidance on the model of staffing, training and experience for midwives providing home birth care.

See also: NHS England's letter responding the Prevention of Future Deaths report.

• The urgent care pathway across Nottinghamshire, whilst working well for most patients, poorly serves patients with systemic illness that is serious, but not immediately life threatening, (such as is seen in sepsis), and where clinical assessment disposition reached is for a Category 3 ambulance response.
• There remains detailed information in the EMAS Computer Aided Dispatch (CAD) transferred from the 111 service that is not reliably read or considered by EMAS staff, when cancelling a requested ambulance response and referring a case on to the Clinical Assessment Service provided by NEMS.
• Families, waiting for an ambulance response, following a clinical assessment by a 111 clinical adviser are not told by EMAS that an ambulance will not be sent.
• Category 3 calls are viewed by non- clinicians at the EMAS Emergency Operations Centre, who do not have sufficient skills to safely transfer calls to NEMS, as the inclusion/exclusion criteria are open to interpretation.
• There is no agreement between EMAS and NEMS as to the criteria for transfer of a category 3 call, including whether or not a previous clinical validation would preclude transfer to NEMS.

• Any individual may conduct a Non-Therapeutic Male Circumcision (NTMC) without any prior training or any Continuing Professional Development (CDP),
• There is no system of external accreditation and/or registration for individuals who
• conduct a Non-Therapeutic Male Circumcisions (NTMC).
• There is no requirement for any record keeping for individuals who undergo a Non-Therapeutic Male Circumcisions (NTMC).
• There is no system for consent to be taken prior to a Non-Therapeutic Male Circumcisions (NTMC).
• There is no requirement for any infection control measures for a Non-Therapeutic Male Circumcisions (NTMC).
• There are no requirements for any aftercare for a Non-Therapeutic Male Circumcisions (NTMC), including but not limited to dressing the wound, analgesia and/or worsening care advice.

In June 2014 Oscar Barker and Yousef Al-Kharboush received TPN, compounded by a commercial provider, which it turned out was also contaminated by Bacillus cereus (subsequently typed as Bc.44). The compounder having positive finger dab testing for the Bacillus within its laboratory/environmental testing. This outbreak also affected other babies in other Trusts. 

Bacillus cereus is resistant (because it is spore forming) to the spray and wipe cleaning methods used (with alcohol) and sporocides are required to decontaminate the outside of, for example, ampoules containing one of the constituents. 

This was the information and a conclusion that the Trust had reached in early 2014 and therefore prior to the outbreak in May/June 2014. It had not passed on those findings either within other section 10 units compounding TPN or the wider market. Subsequently, the MHRA brought in further advice for the use of sporocides in 2015. 

Matters of concern

• There is no requirement for a section 10 exempt entity to report any of its findings to the MHRA or indeed to other Trusts or the industry in general if an adverse event occurs.
• The current reporting structures (for a section 10 entity) involve reporting to NHSE and the CQC but the threshold or necessity for such reporting appears unclear and, in essence, up to the Trust.
• There may be times when section 10 entities reach conclusions which would assist the wider industry and help to assist both other Trusts and commercial organisations in assessing their own risks and improving the provision of highly specific medication to a group of vulnerable patients.
• The same may also be true of commercial organisations but they have the power of the MHRA controlling and effecting recalls and actions and the wider dissemination of information.

Response from NHS England

1. In accordance with the PSII report (#SE-48448 ), a specific recommendation was made that “All clinical staff (medical and nursing) using automated CSF drainage systems such as Liquoguard must have completed adequate training to ensure that they are familiar with the functionality of the device prior to use...” 
2. The evidence at inquest was that this training was not mandatory at present, and that at the time of the inquest, approximately 55% of the relevant staff have received the training. This has been slowed down somewhat due to a representative of the company being off sick, but further training sessions have been planned. 
3. However, the evidence of [REDACTED] (author of the PSII report and consultant neurosurgeon) indicated that it was his view that the training should be mandatory, and that consideration must be given to ensuring this is rolled out in a “sustainable” way to staff – both current and future – as opposed to a “knee-jerk reaction” where training is only given to a limited number of staff following an incident. 
4. There was no evidence before the court that there was any plan to embed this training and ensure that it is carried out in a “sustainable” way, with a particular focus on ensuring that future staff are adequately and properly trained. This was particularly concerning given the apparent high rotation and through-put of staff in the ITU department. It became apparent to me that the training being offered was the type of “knee-jerk reaction” that [REDACTED] was fearful of. 
5. There is a risk of future deaths occurring where clinical staff (medical and nursing) do not receive adequate training on equipment. 

• Lack of clinical governance of the Community Urology Service (CUS) by the Integrated Care Board (ICB) who commissioned the service and Sussex Medical Chambers (SMC) who were responsible for providing the service. The Coroner states that neither the ICB nor SMC were able to provide any evidence of robust clinical governance or multi-disciplinary team processes to ensure best practice of urology services from inception to date.
• Lack of Integration of the CUS with NHS Hospital Urology Services. The Coroner said that the ‘silo’ effect of these two services was such that they effectively worked independently of each other.
• There was an absence of any appraisal and/or mandatory assessments within the CUS or the ICB and SMC for the associate specialist clinicians who were working extra-contractually outside of their NHS work.
• The Coroner notes that this case gives rise to a concern that there is a lack of robust assessment and guidelines, both locally and nationally, as to how clinicians are given practicing privileges to work independently outside of the NHS to the potential detriment of patient care.
• The lack of an independent review prevented any proactive learning and changes in practice following the death of Mr Hankin. The Coroner stated that this gives rise to a concern that the system within the ICB and SMC are insufficiently robust and could – as it was with Mr Hankin – prevent transparency and openness as to the circumstances of his death and limit any learning and or necessary changes in practice to prevent future deaths.
• There were multiple omissions in the pre-operative, intra-operative and post operative care provided by Goring Hall Hospital which individually and collectively contributed to Mr Hankin’s death. This included a failure to recognise Mr Hankin underlying medical co- morbidities rendered him unfit to have his operative procedure at the hospital.

Matters of concern

Due to the age of the hospital building, maintenance is a constant battle. There are also capacity issues in Critical Care due to patient volumes. Building infrastructure had been a constant feature on the corporate risk register and was now scored at its highest level. Whilst measures have been put in place to safeguard against moving patients who require critical care from the Critical Care Unit, there remained fears that these systems would fail during times of pressure.  

Department of Health and NHS England

In 2023 the National Suicide Prevention Strategy 2023 for England highlighted the critical role of 24/7 crisis text services. The roll out of crisis text services across the country in 2024/25 was a key action and commitment in the Strategy, funded by an allocation of £7million to ICBs included in the NHSE Urgent and Emergency Care recover Plan.

• (a) The NHSE indicated in their April 2024 Crisis Text Support Guidance and Specification document that they will oversee the rollout of these services which was expected to be rolled out by the end of March 2025. This has now been extended to March 2026.As of to date the evidence indicates only 10 have set up such a service with another 11 in the process of doing so. Some ICBs have indicated that they have no plans to do so.
• (b) At present this gap in a health-related service is being filled by charity organisations who have different policies and processes regarding actions to be taken if a person is at immediate risk of suicide. The charities are not under the Department of Health so there is no standard policy or procedure for them to follow if there is a real and immediate risk to a service users’ life.

Hence there is a lack of consistency as to the support an individual can receive when there is an immediate risk to their life, for example whilst the charity involved in this case have an agreement with the Metropolitan Police Service to help locate someone whose whereabouts are unknown, this is not the case for all charities.

In addition, as they are not linked into local NHS Trusts, they have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services.

Greater Manchester Integrated Care Board

• Within the Greater Manchester Area there is no commissioned crisis text mental health support service. Whilst GM residents can message national services, often the location of an individual texter will not be known.
• The court heard from Greater Manchester Police that they receive a significant number of referrals which have been sent by this crisis service to the Metropolitan Police, almost one a day where there has been a real and immediate risk to a person’s life identified. All of these referrals require an immediate police response (they are outside of Right Care Right Person). If there was a GM commissioned service, it is likely that any search for the location of the individual would be done by GMP and would shorten the timeframe in which they could respond to the risk.
• In addition, a GM commissioned service would have a greater understanding of local pathways in order to refer people who may have a deteriorating mental health before they reached the point of crisis.

There was a delay in Daisy’s caesarean being performed due to a combination of factors which involved a failure to communicate appropriately between staff and a lack of training on recognising the significance of abnormal foetal movements and foetal compromise generally.  

Daisy was moved to Southmead Hospital Bristol on 9 February 2022 and died in a Children’s hospice in Barnstaple on 22 February 2022 .  

Although the inquest ultimately determined that the brain injury to Daisy was already present when she attended Yeovil maternity unit and that an earlier delivery would not have made a difference to her survival the following findings of fact were made as the timing of the injury was an issue at inquest and the delivery process raised a number of concerns:

• The Consultant who was working remotely, was not fully aware of the staffing issues on the ward, and this meant that she did not fully consider with all the information whether she should have come onto the unit to assist in person.  
• The Guidance at the time did not include asking a Consultant to attend where there was a presentation outside of the staff’s experience and /or skill set and /or where a significant hypoxic insult was suspected to have already happened.  
• Because of the high acuity on the ward, no one had the time to escalate matters for help or make an accurate note which directly led to no one apart from the Registrar knowing that the Consultant required a call back on Daisy’s abnormal scan within 30 minutes.  
• The Consultant failed to telephone the ward back after 30 minutes which led to a further delay in the caesarean being commenced.  
• No professional telephoned the Consultant back as they were not aware of the plan to initiate a call  
• There was no open discussion between professionals or challenge about whether the initial view of the Registrar that Mrs Mccoy needed a Caesarean was correct. 
• No one looked at the Dawes Redman criteria at 0028 and no one escalated this and the CTG generally to the Consultant who said that if she had been aware of this at 0028, she would have come onto the ward to assist.   
• Multiple communication issues as set out above resulted in the parents being left on their own for about an hour with no action being taken and the likely seriousness of the insult being left unexplained  
• A midwife who gave evidence about the new processes for seeing patients with reduced foetal movements had an incorrect understanding of what the new process was .  

Although certain issues were addressed during the inquest the coroner still remained concerned about the prospect of Yeovil Maternity Unit (which is currently closed) reopening in November 2025 without the below matters being considered  

Matters of concern

1. A lack of training to recognise unusual foetal movements / compromise and implementation of such training.  
2. A lack of familiarity with the processes and polices by midwives to understand foetal compromise.  
3. A lack of training and policies on rapid escalation of emergency events  
4. A gap in policy to provide for both Consultants and or midwives to attend in person where understaffing may lead to patient safety being compromised outside of the recognised situations where this is required under the FIGO guidelines.  
5. A lack of understanding and implementation of the polices that additional staffing in times of high acuity or other emergency situations which if left unaddressed may leave patient safety compromised.  
6. No culture of appropriate professional challenge.  
7. A lack of adequate communication between different health care professionals on the maternity unit. 

Evidence was heard that if a mental health screening assessment is carried out in one part of the country, the results and conclusions reach may not necessarily be immediately available in another part of the country, when a further assessment is carried out. Evidence suggested that such assessments capture important clinical information and the lack of availability of preceding data may adversely influence subsequent assessments. Screening may form the basis for onward referral for formal mental health assessments. Absence of vital background information could result in an incorrect prioritisation for onward referral as it did in this case. The situation is not ubiquitous but does occur due to the use of different I.T. systems in various institutions.

To SSP Health, owners and operators of Carlisle Central Practice, 65 Warwick Road, Carlisle

• It was acknowledged that on 18th the advice “to call back tomorrow” should never have been given and that the telephone appointment the following day really ought to have been a face to face assessment either in surgery or at Thomas’s home. I am concerned that no body or organisation has taken responsibility for Thomas, an elderly man with significant co- morbidities, during his illness. Should this responsibility ultimately rest with a patients general practitioner, if not where does it rest? 

To Cumbria Health (CH)

• Thomas’s case was sent electronically to the service, marked for 2 hour attention. I appreciate why this did not take place as it was impossible for clinicians on night duty to triage a large number of calls waiting while actually visiting and treating their caseload. I note a new “OPEL” system has since been instituted to try to escalate and get extra help as the number of calls waiting increases, but where will these extra resources come from overnight? I am also concerned that the referral from NWAS came as a result of a 999 emergency phone call but there seemed to be no way of telling NWAS that the call had not been dealt with and (presumably) passing responsibility back to them. As referred to above -where does responsibility lie? 

To Northwest Ambulance Service (NWAS) as providers of both 111 and 999 responses in Cumbria. 

• There were multiple calls to 111 and 999 in this case. I was told that there was no alert to a call handler to indicate recent contacts for the same patient with the same condition which might highlight a need for more decisive action. I am also concerned that (as above) there is no system that alerts your control to the fact that a 999 (emergency) case you have passed to another agency has not in fact been dealt with. A further concern refers specifically to the 111 service. At inquest it was questioned whether for out of hours GP services Cumbria had been better served when calls went to a local control room in Carlisle. 

To [REDACTED], Secretary of State for Health.  

• In my summing up after hearing the evidence in this case I explained the legal concept of neglect as a failure to provide basic care and (in this case) medical attention for someone in a dependent condition who can not provide it for himself, and I remarked that I felt Thomas “had fallen through an overcomplex system and was indeed neglected”. I am aware that you are hoping to develop a 10 year plan for the NHS and therefore feel it my duty to highlight this case to you as an example of how overcomplexity has lost sight of a man’s urgent care needs. 

The first call was made by a social worker at 15:46, expressing concerns that: 

1. The Deceased had not attended family contact with her children, which was very out of the ordinary. 
2. There was no reply at the Deceased’s home address, but the Deceased’s dog was present inside.
3. The Deceased’s phone was switched off.
4. None of the Deceased’s family had a key to the property.
5. The Deceased had a history of mental health problems and had attempted suicide on numerous occasions. 

The “Right Care Right Person” decision was no. The social worker was advised by the call handler to ring the ambulance service. The call handler also said that they would speak to their supervisor for the decision to be reviewed. 

The second call was made by the Deceased’s mother at 16:38. The call was made on the 999 number. The call handler asked the Deceased’s mother if the Deceased had made a threat of suicide today and when the Deceased’s mother said that she hadn’t, the call handler advised the Deceased’s mother to call back on 101. It was acknowledged at the inquest that it was not best practice to have asked the caller to call back on 101. 

The third call was made by the Deceased’s mother (on the 101 number) at 16:44, expressing concerns that: 

1. The Deceased had a history of mental ill-health and suicide attempts. 
2. The Deceased was mean to attend family contact time that day and hadn’t. The Deceased never missed family contact time. 
3. No one had spoken to the Deceased since Saturday (4 January 2025). 
4. Family had attended the house and the Deceased was not answering the door, but the dog was inside and the Deceased would not usually leave the dog alone for that long. 
5. The same lights had been on in the property since Saturday (4 January 2025) and the deceased did not usually leave the lights on.,
6. A chewed up teddy bear could be seen on the living room floor and the Deceased would not normally leave a chewed up teddy bear on the floor for fear that it would choke the dog. 
7. The Deceased’s phone was going straight to voicemail.
8. To the direct question of was there a real an immediate risk to the Deceased’s life the Deceased’s mother said yes, because the police have had to cut the deceased down before from previous suicide attempts. 
9. The Deceased’s mother informed the call handler of the police also attending suicide attempts at the train lines.
10. The Deceased had recently been reading court papers, which can cause her to spiral downwards. 
11. The Deceased had previously attempted suicide with no warning 

The “Right Care Right Person” decision was no. The Deceased’s mother was advised to call the Mental health Crisis team or NHS 111. The Deceased’s mother said that the social worker had already contacted mental health services and that the social worker had advised the Deceased’s mother to call the police to see if they could do a welfare check. The call handler said that the “Right Care, Right Person” decision was still no, but the decision would be reviewed by supervision. 

The fourth call was made by a social worker at 16:57, expressing concerns that: 

1. The Deceased was vulnerable and over the past six months had attempted to end her life many times. 
2. The Deceased was due to attend family contact time and had not turned up and she would never miss family contact time and this was really concerning.
3. The family had attended the Deceased’s address and the dog was barking inside, but there was no sign of the Deceased. 
4. The lack of contact was unusual, as often the Deceased would cry out for help and contact the Crisis team. 
5. The police had had to break the door down previously to get in to cut the deceased down. 

The call handler said that she could not confirm if a welfare check would be done. Very shortly after this the Deceased’s family forced entry into the Deceased’s home address, and found the Deceased hanging by a ligature.

Matter of Concerns

1. During the 16:44 call, by following the “Right Care, Right Person” procedure there was a refusal to the request that the police attend, even when a family member was expressing the view that there was a real and immediate risk to life. 
2. During the 16:44 call the “Right Care, Right Person” advice to contact mental health services appears to have disregarded the fact that the mental health crisis team do not have the power to enter locked premises and so would require police attendance to facilitate entry to the premises. 
3. During the 16:57 call there was no decision for police to attend, even though this was the third caller (and second professional caller) that had expressed serious concerns about the Deceased. 
4. Although there is a procedure in place to have a negative “Right Care, Right Person” decision reviewed by a supervisor, this causes additional delay in circumstances when attendance could be extremely time-sensitive. 

To The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust

• I considered evidence from a [REDACTED] who indicated at paragraphs 20-21 of his statement, “I did not see any record of his pulse, blood pressure or oxygen saturation. The normal practice is to complete these observations, and I would expect this to be done, especially with him presenting with chest issues. However, I am unable to comment why this was not recorded or confirm that these were carried out. (21) This is a learning point for the department, and I have taken steps to ensure this learning is taken forward by theTrust. I have alerted the Sister in charge of the Spinal Injuries Outpatients’ Department and requested that adequate measures are taken to ensure that all observations made are recorded in the outpatient forms…” 
• It was unclear whether this was a single one-off event involving human error or indicative of a wider and systemic issue involving a lack of training. There was no evidence before the court that this “learning point” had been actioned or that any adequate steps had been taken to ensure proper and accurate recording of records by staff. 
• There is a real risk of future deaths occurring where staff do not have adequate training and that patient records are not being properly completed. 

To NHS England / Department of Health and Social Care

• I heard evidence that The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (“The Trust”) have been experiencing difficulties with patient waiting lists – due to both an increase in the quantity of patients being treated and staffing shortages – which has led to patients waiting longer than is reasonable or necessary for reviews and treatments. As part of the inquest, there was evidence that Peter Anzani himself had been waiting for nearly a year for a follow-up review, which should have been carried out after no more than 6 months. 
• I heard evidence from representatives of the Trust that they have repeatedly requested additional funds for workforce development and expansion to assist with cutting patient waiting lists and waiting times. I understand that an initial Workplace Funding Review was submitted in 2023 but was rejected by NHS England due to a funding shortage. I understand that a further Workplace Funding Review was submitted in the Autumn of 2024, but in February/March of this year, NHS England indicated that the same would again be rejected under a “no growth policy”. 
• Whilst naturally I am aware of the pressures on the public purse and on the NHS generally, it is concerning to hear that the Trust do not appear to be being adequately supported financially by NHS England, and do not currently appear to be able to address their workplace staffing issues without additional financial support (which does not appear to be forthcoming). 
• It is obvious that where patients are waiting for longer than is reasonable or necessary for treatment or reviews, there is a real risk of deaths occurring. No patient should be waiting longer than absolutely necessary for treatment. 
• In light of HM Government’s decision on 13 March 2025 to abolish NHS England and for its role to be subsumed within the Department of Health and Social Care, this report is being sent to both Agencies to consider, as it relates to issues of both a local and national significance. 

• In the case of Mr ME, a significant surgical error was made when a healthy part of the bowel was removed instead of the area with the cancer, resulting in a much more extensive operation and Mr ME dying around 5 weeks later. This was discussed in a morbidity and mortality meeting, which ends with the simple phrase “await coroner’s report”. A structured judgment review was carried out by a consultant colorectal colleague on 4 May 2024, over four months after the death. According to this review, all of the care given to Mr ME was either “good” or “excellent”.
• A further structured judgement review took place. It would appear that none of the colorectal surgeons was willing to carry this out, resulting in the need for a gastroenterologist to conduct a second review in July 2024, by which time the surgeon had already been suspended from major operative work.
• It is important to note that in a clinical governance meeting in February 2024 (ie before either of these structured judgement reviews) it was noted that there were “no learning points identified” in relation to Mr ME’s case.
• In the case of Mr MR, a structured judgement review took place conducted by a consultant surgical colleague. This report was poor and the coroner wrote to the Chief Medical Officer about it after the inquest. It has the look of the briefest of reviews and tick box exercises. Again, all of the management is referred to as “good”.
• Mr MR’s case was not discussed during the March 2024 morbidity and mortality meeting, despite the fact that a later death (Lorraine Parker’s, on 30 March 2024) was discussed then. Mr MR’s case did not go to a morbidity and mortality meeting discussion until May 2024. The reasons for this remain unclear.
• In Lorraine’s case, there was a morbidity and mortality meeting discussion in March 2024 (or perhaps shortly thereafter). The April clinical governance meeting minutes refer to Lorraine’s case and again state “no learning points”.
• None of these three cases has been the subject of a detailed PSIRF report.

Matters of concern

1. On the evidence from the three inquests referred to, the Royal Berkshire Hospital’s death investigation process is not working well.
2. Evidence of delayed morbidity and mortality meetings with no clear system for ensuring that these discussions happen timeously.
3. There is little (if any) record of areas of concern identified at meetings – whether at morbidity and mortality meetings or clinical governance meetings.
4. There is delayed escalation of concerns.
5. Structured judgement reviews are at best, poor, and at worst, defensive.
6. Delayed or no scrutiny of cases being reported to the coroner because the cause of death is unnatural, given that medical examiners are not funded to scrutinise those cases. Opportunities for early learning are therefore being lost.
7. Systems of collating and providing medical records and clinical governance records to the coroner (and presumably to others involved in death investigation) are unreliable.
8. The coroner is concerned about whether the trust has done enough to deal with the concerns about this particular surgeon, not just in the Berkshire area, but more widely.

Overnight leave arrangements

When Anne was sent on her first overnight leave there was no codified ‘risk’ and ‘safety planning’ document. While in Anne’s case the report notes that it was widely accepted that her husband was well versed and knowledgeable about his wife’s risks and the measures that might be necessary to help keep her safe whilst she was at home, the Coroner noted that this may not apply in other cases.

The report said that whilst families are not mental health practitioners and are not expected to adopt that role within the community there appears to be an opportunity to supply families with a short, codified document dealing with salient points of risks and safety planning when a patient goes for their first overnight leave since being detained. The Coroner suggests that this could help equip families with the knowledge to spot signs of declining mental presentation and/or risk and provide them with the knowledge and/or tools to take appropriate steps to assist in safeguarding their loved ones while they are in the community. 

Internet access in mental health settings

The report notes that it found that if an in-patient (detained or voluntary) accesses the secure unit Wi-Fi there are no algorithms or ‘search detection features’ to prevent access to websites pertaining to self harm and so these can be readily accessed by a group who are already vulnerable due to their acute mental health presentation with some element of inherent risk of suicide. 

The Coroner noted that workplace organisations do have the ability to block sites if they deem it undesirable for their workforce to access (such as sites relating to gambling, sexually inappropriate content, etc). The report states that by allowing an already vulnerable group to have unfettered access to websites dedicated to self harm creates a risk of further deaths. 

Menopausal care

The Coroner noted several areas of concern about menopausal care available on the NHS:

• Menopausal training is not mandatory in any area of clinical practice or specialism. The Coroner expressed concerns that there is no requirement to undertake essential compulsory menopausal training for those working in ‘relevant’ clinical practices such as mental health practice, obstetrics and gynaecology, and oncology, or even general as a general GP.
• The Coroner noted that she was told that the Trust has just one ‘menopause specialist’ (a GP) who covers the entire Trust operations. Not all GP surgeries have a menopause specialist practitioner (or access to one) despite a GP usually being the first port of call for women in the community when seeking primary care. Those GP surgeries who do have a practitioner who acts as a ‘specialist’ is often a GP with a personal interest who has taken the initiative to go on courses and broaden their learning and understanding, rather than any mandatory requirement for a surgery [or group with multiple surgeries] to have an available community ‘front-line’ specialist.  

She also noted that:

“I was told during a previous PFD Response relating to menopausal knowledge and care within the NHS that “It is important to ensure that women understand common symptoms such as anxiety, stress and depression which they might experience during the menopause and where and when to seek help. The NHS website has resources….” This emphasises my concerns entirely; the lack of importance given to menopausal symptoms. If someone has concerns about heart disease, a worrying lump, a broken bone etc they expect to be able to consult a medically qualified professional who has a knowledge and understanding of their condition or presentation and can diagnose and treat accordingly; not just [and I paraphrase] ‘have a look at a website to help’.”

Concluding, the Coroner referenced being told in a response to a previous Prevention of Future Deaths report where she raised similar concerns about a roll-out of specialist menopausal care and upskilling of GPs. She stated that from reviewing this case there was little evidence that this has happened/is happening and said that women continue to approach and navigate the menopause without the support of expert clinicians or practitioners who understand and can treat the symptoms they are experiencing.