• The hospital arranged for Mr Brookes transportation home without rearranging the required care.
• There was no record or documentation or process to show or demonstrate that the care had been rearranged.  
• The transport company were responsible for transportation only and were not required to notify either the hospital, or if known, the care company of Mr Brookes’ safe return. It proceeded on the basis or assumption that care would have restarted within 4 hours or sooner.  
• Mr Brookes did not have his alarm pendant around his neck and nor was his mobile phone available (it was in another room). Accordingly when Mr Brookes got into difficulty he could not raise the alarm or call for help. 

A: Culture of Candour [Trust, ICB and DHSC]

1. I am concerned that there is not a culture of candour within University Hospitals of Morecambe Bay NHS Foundation Trust (Trust) and the impact that this has on safety, learning and implementing required changes to prevent deaths. Urgent action is required by the Trust to meaningfully embed the Dury of Candour.

2. [REDACTED]’s evidence to the inquest was that a deep-seated and endemic culture within the Trust leads to denial and a failure to learn. [REDACTED]’s Investigation report was published in 2015, the Trust is ten years on and still issues and themes identified in 2015 were very much in issue in 2019 and still exist at the Trust as identified by Ida’s inquest. 

3. The Trust’s approach to the inquest has been one of a lack of transparency and openness, failure to provide relevant information and a failure to identify with candour the defective clinical governance processes that have operated at the Trust from 2019 to present day. 

4. The Trust did not disclose that they had failed to notify the external bodies namely the CQC and the then CCG [ICB] via STEIS and the Trust’s internal Serious Incidents Reporting Investigation panel, none of which was noted by the Trust’s Patient Safety Summits .The matter was reported to the Coroner a year after Ida’s death by the family after the Trust took no action to do so, despite being on notice of failures in treatment from the HSIB report Ida’s harm was at no point categorised by the Trust as a harm event that caused “death”. 

5.  Trust figures to the Board provided in 2025 stated that there were no complaints over 6 months old when the Trust at the time of the inquest have not responded to [REDACTED] and [REDACTED]’s 1 June 2020 complaint. Together with the Trust’s failure to categorise Ida’s death as only “Moderate Harm” (see point 4 above) cause me also to have concern about the reliability of Trust’s data.

B: Clinical Governance and Maternity Governance [Trust, ICB and DHSC]

6. I consider the clinical governance arrangements at the Trust require urgent review to ensure the appropriate personnel are in place, with the necessary training and skills to deliver robust clinical governance to ensure patient safety in maternity care. 

7. As a result of the Trust’s deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust’s clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self- congratulation. The clinicians’ reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence. This approach caused additional distress to the family who had to sit through an extended court hearing to address these issues 

8. [REDACTED] is now Head of Compliance and Assurance at the Trust but that there has been no investigation into her role in respect of reneging on the Trust’s acceptance of the HSIB report at senior management level and with the family as was indicated by her approval of the July 2021 position statement. Similarly, [REDACTED] is now Head of Midwifery at the Trust and there has been no investigation in respect of her disputing the HSIB findings and submission of challenge to the HSIB report in Ida’s case. 

9. All investigations conducted by the Trust to date in respect of Ida’s death have been unskilled, superficial, brief, failed to identify issues and left the family without answers and were all features identified by the 2015 Kirkup Report. In view of the continuing culture at the Trust, this cause a significant concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality and serious injury by the Trust.  

10. The Trust’s clinical governance capability has been the subject of repeated and often severe criticism in the Flynn Review 2009, Fielding Report 2010, Central Manchester Hospital Report 2011, Price Waterhouse Cooper 2012 and Kirkup Report 2015. [REDACTED] in his evidence to the inquest said that the Trust focus on process, which means that you can comply with the process requirements and still produce an inadequate investigation, rather than focussing on outcome, which measures the quality of the investigation and the patient experience. [REDACTED] noted that the Trusts culture impeded transparent and open investigation. I am told that the Trust now uses the PSIRF model and is to appoint 3 whole time equivalent Response Leads by 30 September 2025. However, I remain concerned that the Trust has not fully engaged with the duty of candour such that I am not satisfied that the work on PSIRF to date has truly addressed the issues in respect of Trust’s investigations. 

C. Mandatory Training, expired training and remedial training [Trust and ICB]

11. The Band 5 midwife supporting [REDACTED] in Labour had not undertaken her required mandatory training and this fact had not been provided and was only revealed at the inquest as part of the evidence of the Head of Midwifery in March 2025. I was also concerned to learn that in 2025 non-completion of mandatory training was still an issue as [REDACTED] had not completed her mandatory training. 

12. It concerns me that the Trust do not have robust systems in place to ensure that any midwife who has not completed her mandatory training is subject to immediate action to ensure that all mandatory training is completed and is in date. 

13.  There was no remedial training was put in place for either the midwives involved in Ida’s delivery and resuscitation or for the paediatric SHO after Ida’s death. This raises a significant concern that the Trust do not operate a system of remedial training when this inquest has identified remedial training was required for [REDACTED], [REDACTED], [REDACTED] and [REDACTED]. 

D. Grading of harm for incident reporting: Babies who have sustained hypoxic brain injury and undergo cooling [Trust, ICB, DHSC, NHSE, [REDACTED]] 

14.  The Trust graded Ida’s level of harm as “moderate”, even after her death. This grading should have been adjusted to “severe” by the Trust before Ida was transferred to Royal Preston Hospital as the consultant paediatrician identified that she had sustained a severe hypoxic ischaemic encephalopathy due to fetal bradycardia. 

15.  The 2024 NHSE Learn from patient safety events (LFPSE) guidance that replaced the National Reporting and Learning System (NRLS) confirms that the recording and analysis of patient safety events that occur in healthcare support the NHS to improve learning from patient safety events to help make care safer. There is a significant risk that if reporting is graded on harm alone, clinical care that resulted in hypoxic brain damage during delivery and which was prevented by therapeutic cooling, will not adequately identify the problems that caused the harm during the delivery. 

16. [REDACTED] confirmed that nationally there is inconsistency in categorisation of harm for babies who sustain a hypoxic injury due to fetal bradycardia in labour and who require cooling and clarification guidance would assist prevent further maternity deaths and ensure full and proper investigation of hypoxic injuries sustained in labour. 

E: Funding for MSNI [DHSC and [REDACTED], NHSE and ICB]

17. But for the HSIB investigation report into Ida’s death [REDACTED] admitted that Ida’s death due to failures by the Trust would never have come to light or resulted in an inquest.

18. The MSNI is now hosted by the CQC with funding secured for the next two years but no certainty as to ongoing funding after this date. These independent investigations by specialist skilled investigators into the most serious of events is an essential safeguard to the lives of mothers and unborn children.

19. Without an assurance that funding will continue beyond 2027 I am concerned that significant harm events to mothers and babies and deaths such as Ida’s will go unrecorded and lessons that should be learned to prevent future maternal and baby deaths will go unnoticed, and there will be a risk of future maternity deaths.

1. On the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations.  Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical  review  would  have  changed  the  course  of  her management and saved her life.  
2. The registrar who saw Billie the night before her death prescribed an antibiotic, but he was not in the habit of giving the first dose in the department and he did not on this occasion. This meant that Billie’s infection was not tackled as quickly as it could have been. This seems to indicate a training and potentially a guideline need.
3. At the time of Billie’s presentation, the registrar was unaware of the possibility of adult onset asthma. This seems to indicate a training and potentially a guideline need. 
4. I heard that Billie was safety netted when she was discharged. Her parents were told to bring her back if they had any concerns.
5. I have heard this safety netting advice being described many, many times in different inquests. What worries me about it in this context is that Billie’s parents had brought her to hospital because they were concerned. They were then reassured by hospital staff. It is therefore difficult to see how this particular advice could be a meaningful instruction.  In reality, her parents’ initial concern was well placed and they had responded to it appropriately by bringing Billie to hospital. When Billie began to deteriorate again, her parents’ natural instinct had been blunted by their first visit to the hospital. 
6. Whilst I doubt that it would have made a difference in this case, I understand that blood pressure is not yet an observation included in the national paediatric early warning score (PEWS).   

Early Day Motions are motions submitted for debate in the House of Commons for which no day has been fixed, and as such very few are debated. They are used to put on record the views of individual MPs or to draw attention to specific events or campaigns. By attracting the signatures of other MPs, they can be used to demonstrate the level of parliamentary support for a particular cause or point of view.

Early Day Motion 867: National oversight mechanism

This Early Day Motion was sponsored by Carla Denyer MP. It reads as follows:

That this House believes that the State owes it to bereaved families and victims to learn and implement lessons from deaths involving the State and corporate agencies; notes that the Grenfell Inquiry recognised a failure of the State to follow up on recommendations made by inquests and inquiries; acknowledges the Government’s commitment to a publicly available record of these recommendations as a step in the right direction; urges the Government to also create a national oversight mechanism to ensure that these recommendations are routinely monitored by an independent body to help enact learning and prevent future deaths; further notes that such a Mechanism would go beyond facilitating transparency and ensure accountability, which is desperately needed for bereaved families and for public confidence; and believes that for victims of large scale tragedies such as Hillsborough and Grenfell, as well as victims of individual state failings, the Government must ensure that lessons are learned from their deaths and the same mistakes are not repeated.

Related reading

• Inquest - No More Deaths Campaign
• Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS

1. The term ‘Physician Associate’ is misleading to the public.

Mrs Marking’s son was under the mistaken belief that the Physician Associate was a doctor by this title in circumstances where no steps were taken by the Emergency Department or the Physician Associate to explain or clearly differentiate their role from that of medically qualified practitioners.  

2. Lack of public understanding of the role of Physician Associate.

Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety.  

3. The right of patients and family to seek a second opinion.

The lack of public knowledge that a Physician Associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a Physician Associate rather than a medically qualified doctor. 

4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate.

A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in an abdominal examination in a patient who was unable to give a proper clinical history because of short term memory loss. No evidence was presented that the management of Mrs Marking was subject to a reflective practice review. Given their limited training and in the absence of any national or local recognised hospital training for Physician Associates once appointed, this gives rise to a concern they are working outside of their capabilities. 

5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates.

Whilst there were discussions with the ‘supervising’ consultant the Physician Associate was effectively acting independently in the diagnosis, treatment, management and discharge of Mrs Marking without independent oversight by a medical practitioner. This gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety. 

6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery.

Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice. 

7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI.

Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4).  

8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic.

Evidence was heard that as cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved. 

• Whether there is adequate communication of the risks of suicide associated with the selective serotonin reuptake inhibitor (SSRI) medications, and
• Whether the current guidance to persist with SSRI medication or switch to an alternative SSRI medication is appropriate when no benefit has been achieved and/ or especially when any adverse side effects are being experienced.

• The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting beds. In Matty’s case a bed was not found for them within a 26-day period.   
• There being a shortage of beds for Autistic patients (both informal and detained) within the private sector that are being funded by the ICB. Evidence was heard that those providing beds within the public sector very often refused to accept autistic patients due to their additional risks.  
• There being a shortage of beds for transgender patients who are in need of a mixed ward.  
• In Matty’s case it appears there was a lack of appreciation by the ICB of his extensive length of stay in A&E. It appears that this information (and others who had lengthy stays) was not at that time being collected, monitored and acted on by the ICB.  
• The unsuitability of the environment of A&E as a holding place for those in need of a mental health bed. The evidence was that the environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse. The environment in A&E can exacerbate and cause further deterioration in their mental health.  
• There is a gap in services for those who are not ill enough to be detained but who are too high risk to be sent home. 
• There is a significant wait time for referral to the Assessment and Treatment Service. Therefore, any therapeutic input is delayed, and this results in repetitive attendances at A&E when in crisis. 
• Current gaps in service around psychosocial support for transgender, non-binary and intersex adults have been provided by third party charitable organisations. It is understood that much of their funding has recently been withdrawn by the ICB. This is of particular concern as Brighton is recognised as having one of the largest trans communities in the Country.  

It was confirmed in evidence, the order for the equipment from NRS Healthcare was placed correctly on 10 January 2024, on a next day delivery basis. 

Matters of concern

NRS Healthcare related matters:

• The coroner heard evidence of a delay in delivering some of the required equipment, which in turn meant a delay in the patient being able to make use of the equipment. The delay meant that the patient’s family, carers, and the district nursing team underwent a period of time in which they were unable to provide the patient with the optimal care required in relation to the pressure ulcer. 
• When the TOTO turning system arrived it was defective. An urgent repair/replace request was made to NRS Healthcare, which resulted in an engineer attending the patient’s home to replace the pump on 23 January 2024. However, despite advising that they had replaced pump with a like-for- like pump, it transpired that the replacement pump was a ’Tri-Pos Bariatric Alternating Air Cushion’ pump. This replacement pump had none of the settings that would allow the proper and effective use of the TOTO system. In this instance, the TOTO system was required to turn the patient from one side to the other every 60 minutes. I was told in evidence that equipment issues would have added to the patients ‘pain and distress’ and the fitting of the incorrect pump meant that the patient was not being turned every 60 minutes, as required. Again, this creates the risk that those caring for the patient were precluded from providing an optimal level of care. 
• While the presence of a pressure ulcer, in itself, did not add to the underlying risk of the patient developing a pulmonary embolism, the delayed and defective equipment provided significantly increased the patient’s immobility in the weeks prior to her death. There was evidence that immobility is a major risk factor in the development of pulmonary emboli.  
• The coroner heard evidence that issues with delays and defective equipment from NRS Healthcare persist to date. 

NRS Healthcare and NHS England related matters:

• The coroner heard evidence that since being awarded the contract to provide such equipment, there had been numerous and ongoing delays and ‘problems’ in the service provided by NRS Healthcare. The evidence was such that the repeated issues and concerns had actually been placed on the Trust/Integrated Care Board’s (ICBs) risk register. While I heard that there had been some improvement, I was told that the service provided was still ‘not great’. 
• While this particular case is the first in which the coroner has formed the opinion that delayed and defective equipment has created a risk of future deaths, he has heard similar evidence of delayed and defective equipment issues relating to NRS Healthcare in other inquests concerning different NHS Trusts and ICBs. On that basis, the coroner is of the opinion, given NRS Healthcare’s operations are not confined to organisations within this coroner area, that the risks posed are likely to be more widespread and that action should be taken more widely. 

• Due to Harry’s level of agitation, he did not undergo the level of observations  that would and should have happened either in the emergency department or  once on the Mason Unit which may have assisted in assessing his physical health.  
• It was clear that none of the mental health nursing staff were aware of ABD and  the fact it is a medical emergency.  
• The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters.”  

The full report can be found via the link below. You can also read the Royal College of Nursing response here. 

The TICKS acronym was prepared by the (now disbanded) UK consortium of sling retailers and manufacturers

• tight 
• in view at all times 
• close enough to kiss 
• keep chin off the chest
• supported back.  

There appeared to be no advice in the literature regarding the risk of baby slumping and the risk therefore of suffocation, particularly if baby is under the age of 4 months, and no advice that breastfeeding “hands free” a young baby is unsafe, due to the risk of suffocation and not being able to meet every aspect of TICKS. 

There appeared to be no helpful visual images of “safe” versus “unsafe” sling/carrier postures. 

Evidence was given by the witnesses assisting the inquest that public information, readily available, not too complex but consistent in message would be welcomed to advise and instruct. 

Matters of concern

1. There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings 
2. This is notwithstanding a significant increase over recent years in the use of such equipment. 
3. The question of whether it is safe to breastfeed “hands free” is not addressed or referred to in the public domain or manufacturers literature.
4. The NHS available literature provides no guidance or advice.
5. The only current “tips” are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful 
6. Young babies are at risk of suffocation.
7. Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory. 

Queen Alexandra’s written post operative care pathway for patients who have undergone a gastric bypass operation states that:

There is to be a daily review by a bariatric specialist nurse, consultant or registrar.

A senior doctor is to review within 2 hours if there is increased abdominal pain in order to rule out anastomotic leak or bleed.

In addition to this, the inquest heard evidence that patients should be seen by a member of the specialist bariatric team prior to discharge. This is not included in the written policy.

Neither the written nor informal policy set out above were followed in Ms Evans’ case. She was not reviewed by a member of the specialist bariatric team at any point on day 2 after surgery and the pain she experienced from the early hours of 13 July 2023 was not escalated to a senior doctor at all. The inquest heard evidence that medical staff who were not part of the specialist bariatric team were unlikely to appreciate the significance of pain.

The failure to follow policy contributed more than minimally to Ms Evans death and is therefore a matter of concern.

• The evidence revealed that there is currently a widespread shortage of available placements for someone with Declan’s complex needs both in the community and within the NHS. 
• Once it was clear that Declan’s community placement had broken down in late 2021 no suitable alternative could be found. This resulted in a decline in Declan’s mental health and behaviour which ultimately necessitated his detention under the Mental Health Act. There was then nowhere suitable to detain him under Section 2 of the Mental Health Act. 
• The Section 136 Suite was completely inappropriate. Declan’s mental health and behaviour declined further and ultimately this resulted in his death. 
• Declan was in crisis for several months – the facilities were simply not available in the community and once detained, in order to prevent his death. 

• The causes of the ambulance delay were that all available resources were managing incidents of a higher acuity or the same category but registered prior and there were significant handover delays across all BCUHB sites.
• The matters of concern are longstanding and multifactorial and despite proposed future action significant concerns remain. The Welsh Ambulance Service NHS Trust and Health Board maintain that they are continuing to work closely in border to address handover delays and yet any improvements appear extremely limiting. Deaths are occurring and will continue to occur as a result of delayed ambulance attendances caused by these multifactorial issues.

• During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so. The area is not designated as a clinical area and is not included within the Nursing staffing template for the ED. When Ms Davis was treated in the Royal Sussex County Hospital, Brighton on 11 December 2022 there were, at times, more than 20 patients in that area.
• Clinicians from University Hospitals Sussex NHS Foundation Trust gave evidence as to the action that is being taken by the Trust currently to (1) reduce the number of patients who present to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital. The evidence was however that, despite these actions, the corridor remains in use for patients currently as there is insufficient space within the department to care for patients. There was no evidence as to when, and if, this practice would no longer be necessary.
• I heard that the provision of care in the ED corridor meant that patients lacked privacy, toilet facilities and confidentiality. I understood from the evidence of the clinicians that they were concerned that patients were being moved into the Corridor but there appeared to be no other option when the Emergency Department exceeds capacity. I heard that in the event of a major incident University Hospitals Sussex NHS Foundation Trust would have to clear the Emergency Department, as they had done on occasion, as this would be the only way to create the necessary clinical space when the department was already over capacity and using the corridor.
• I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country when the capacities of Emergency Departments has been reached and there is nowhere to move patients to.

• The medications were provided to the couple by the local pharmacy, then known as Lloyds Pharmacy, in separate dosset boxes. Mrs Chaddha’s medications were provided on a weekly basis. Mr Chaddha’s were provided on a monthly basis.
• Both patients were elderly and had cognitive impairment.
• (The two patients’ dosset boxes were identical to each other except for a small pharmacist’s label with small type with the relevant patient’s name.
• Mrs Chaddha used one of Mr Chaddha’s dosset boxes, rather than her own, for several days.
• Evidence was given at the inquest that there was no guidance or policy in place for Pharmacists to follow when issuing medication to patients with cognitive impairments, or if there was, it was not well disseminated among the pharmacist population.
• Evidence was given at the inquest that dosset boxes of different colours or labels with different colours were not routinely given to elderly or cognitively impaired patients living at the same address.

1. In late 2018 Nigel became seriously mentally unwell and was admitted to a Mental Health Unit, under the Mental Health Act provisions, for a period of 3 months. Whilst admitted, Nigel was diagnosed with advanced lymphoma (a lymphatic cancer) and upon discharge from the Mental Health Unit spent a further 3 months in hospital being treated for this.
2. Nigel found his Mental Health Unit admission very traumatic and was described as ‘terrified’ of the thought of ever being admitted again.
3. Upon his release, his family, carers, Mental Health Home Treatment team, worked together to provide exemplary care for Nigel, whose health stabilised and in 2020 his care was transferred back to his own General Practitioner.
4. Nigel remained well until Friday 8 March 2024, when due to his decline in mental health he was taken to see his GP, and on the 9 March 2024 Nigel was prevented by family intervention from ending his life by jumping into a river.
5. his incident led to Nigel’s family speaking to the on duty Authorised Mental Health Professional (AMHP) from the Suffolk Emergency Duty Service Team, on the evening of 9th March 2024. An AMHP is a mental health professional approved by a local social services authority to coordinate the mental health assessment and admission to hospital, of individuals requiring admission under the Mental Health Act provisions
6. In evidence, the court heard that the AMHP, in line with Nigel’s family and his own wishes, agreed that an admission to hospital would not be in Nigel’s best interest. The AMHP identified that the successful home treatment regime previously in place would be the ideal care package for Nigel. This arrangement would also be consistent with the ‘least restrictive principle’ which surrounds the application of Mental Health legislation.
7. That said, although Nigel did not meet the criteria for immediate admission, the AMHP believed Nigel was mentally very unwell, and in need of immediate support. The court heard that such support would be available within a 4-hour target time, from the emergency Crisis Resolution and Home Treatment Team.
8. However, the court was told that an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team.
9. The court heard that the normal route for such referrals was via the GP Surgery, or primary care Mental Health Nurse, neither of whom in Nigel’s case would have been available before 08:00 on Monday 11 March 2024. Nigel’s fall which led to his death, occurred at 06:25 that morning.
10. I am concerned, as had the AHMP in Nigel’s case been able to directly refer him to the Crisis Resolution and Home Treatment Team on the 9th March 2024, mental health professionals would have attended, and been able to provide additional support, advice and potentially additional treatment for Nigel, in all likelihood preventing his death.  

1. The responsibility for checking and administering the local anaesthetic is unclear:

• a. The instruction was given orally and not written down by the anaesthetist (the
• prescriber).
• b. The anaesthetist did not check what the nurse had written down.
• c. The nurse drew up the local anaesthetic from a stock bag and checked this with
• another nurse, but not with the anaesthetist.
• d. The nurse then handed the drawn-up anaesthetic to the surgeon to administer.

2. There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced.

3. The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation. However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation.

1. Following Juliette’s death, a Structured Judgement Review (SJR) was carried out which identified steps that have been taken. However, the SJR confirmed that a review of Rio records was being undertaken of those who have not been seen in over 12 months with actions to be identified, and that clinical stratification of current caseload is ongoing. It is understood that a review or audit of this process is being scheduled to take place at some point in October 2024 (date unknown). 
2. Upon conclusion of the inquest, the Coroner will have no way of checking if the recommended actions have been completed. In the circumstances, where action to be taken is outstanding and when a specific review date has not been scheduled, the coroner is concerned that there is a risk of future deaths occurring. 
3. The deadline for a response under this Report should coincide with the Trust’s planned review/audit in October, therefore the Coroner is hopeful that the Trust will be able to respond swiftly  thereafter, and hopefully will be able to confirm that positive action that has been taken and whether any further work is necessary.  

• The junior doctor who reviewed Mrs Pollitt decided that an ascitic drain should be placed. However, the Court found that this procedure was not clinically indicated at that time.
• The Physician Associate who undertook the procedure also directed that the drain be clamped due to a concern that the loss of fluid could cause a drop in blood pressure. This was unwarranted given the moderate level of fluid which had been drained and the Court heard that the Physician Associate did not appreciate that clamping a drain increased the risk of infection.
• The situation was compounded by Mrs Pollitt’s placement on a respiratory ward rather than a gastroenterology ward since there was a lack of understanding and awareness across all the staff on the respiratory ward including the medical team as to the management of ascitic drains.

The Coroner set out their matters of concern as follows:

• There is no regulatory body with oversight of Physician Associates. It is understood that this is currently the subject of a consultation by the General Medical Council.
• The Physicians Associate Managed Voluntary Register held by the Faculty of Physician Associates (FPA) is voluntary. Whilst employers are encouraged to check the register there is no duty to do so, nor is it clear how the FPA would be made aware of any concerns relating to an individual Physician Associate.
• There is no national framework as to how Physician Associates should be trained, supervised and deemed competent. This is placing both patients, Physician Associates and their employers at risk. The court heard that since the death of Mrs Pollitt the Northern Care Alliance have put in place a local trust framework. Unlike all other clinical roles there is no national guidance save for very recent guidance issued by the British Medical Association (March 2024).
• There remains limited understanding and awareness of the role of a Physician Associate both amongst medical colleagues, patients and their families. The lack of a distinct uniform and the title “Physician” gives rise to confusion as to whether the practitioner is a doctor.
• In June 2022 the Physicians Associate had been signed off as competent for the insertion of ascetic drains. This sign off was completed by a liver nurse specialist using a competency form which was provided by the FPA. Whilst the competency form assessed the technical aspect of placing the drain, it did not include competency around the wider aspects of care such as taking consent, risk factors and after care.

• Although Mr Ali was meant to be under 15-minute observations, a registered mental health nurse on Lea Ward gave evidence that on 21 August 2020 at around 1740 she saw that the observations board had not been completed for 1700, 1715 and 1730. She then completed it as if she had conducted those observations, recording that Mr Ali was asleep.
• Evidence has been provided by the Trust that since Mr Ali’s death on 26 August 2020, there have been 11 fatal incidents where observation records may have been filled in when observations have not been conducted. One of these, in May 2023, was in Lea Ward, the same ward where Mr Ali was detained.
• Whilst the date and name of the hospital and/or ward connected with each of these deaths have been provided to me, evidence has not been given by the Trust as to the specific circumstances of each death, nor the subsequent individual investigation and findings and any consequential action taken. Nor has this issue been addressed in the Trust’s Action Plan as part of its internal investigation. 
• The Trust has stated that the majority of the 11 deaths pre-date the work that it has been doing to improve practice around observations that has been progressing since Autumn 2022.  
• The Coroner has been provided with evidence that in October 2023, the Trust wrote to staff about ‘Falsification of Observation Records’, stating: “We commenced a Trust wide QI project in September 2022 in response to prevention of future death (PFDs) notices from the coroners. The PFDs highlighted concerns about the quality and consistency of engagement and observation practice. This work has engaged all Directorates in enhancing our appreciation and understanding of the importance and impact of therapeutic engagement and observation. Directorates have been doing work using QI methodology to look at how we can improve standards to ensure consistency and quality in undertaking these…”  
• Further, that “Despite this work, we have seen an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done.” 
• Given the above, the Coroner is concerned that action undertaken thus far by the Trust has not been sufficient to ensure that observations are being conducted and/or recorded as required which in my opinion gives rise to a concern that future deaths will occur.

• Although the wrist alarm had been reported as broken and not working on the 6 January.2024, this was not replaced or repaired by the company engaged by the local authority to provide this service before the deceased fell at home.
•  At the time the deceased fell, she was wearing her wrist alarm but could not use it to summon help because it did not work.
• None of the carers who attended on the deceased after 6.1.2024 ensured that steps were taken to replace the wrist alarm or report the matter to the local authority.
• The last carer who attended on the deceased before she died, on the 11 January 2024, was not aware that the wrist alarm did not work as she had not read the care notes. No clear instruction was given to care workers about the extent to which they would be expected to read the care notes relating to service users.
• None of the carers had been given any training, instruction, or guidance on the testing of wrist alarms to ensure they worked properly when attending upon service users.
• There was no clear system identified between the company providing carers and the local authority, as to the duties and responsibilities of each in the reporting of faults with wrist alarms.
• I am concerned that there is a risk of future deaths arising in circumstances when vulnerable people, who live at home and are reliant of wrist alarms which have been reported as not working, but have not yet been repaired, may unable to summon help.

The Inquest heard that the North West Ambulance Service was unable to meet average response standards at the time of the 999 call mainly due to the fact that ambulances were unable to clear the region’s hospitals because of the long waiting times there. In addition, there were high call volumes. A level 4 incident plan was commenced as a result.

Matters of concern

Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges. This is because resources available in the North West Ambulance Service cannot be fully utilised as a result of the delays in ambulances clearing Accident and Emergency departments.

Measures undertaken by the North West Ambulance Service

A number of measures have been undertaken by the North West Ambulance Service to address emergency response times including:

• Regular meetings take place between the North West Ambulance Service and NHS Trusts in the region to discuss the delays at a regional level.
• There are faster communications between senior leaders in the North West Ambulance Service and NHS Trusts when there is a period of high demand or delay.
• North West Ambulance Service managers are deployed to struggling Accident and Emergency departments.
• A delayed handover checklist is in place.
• Patients are triaged to assess if they can wait in a waiting room to release ambulances – this is called Fit to Sit.
• Patients who can be safely grouped with other patients and looked after by one ambulance crew rather than in individual ambulances are placed together to release ambulances.
• The North West Ambulance Service now has an option to remove crews with 15 minutes notice to the hospital.
• Batch Divert is in place which allows the North West Ambulance Service to send an ambulance to another hospital.

The inquest heard that waiting times across the North West region are still impacted by problems clearing the regions hospitals despite the above measures.

1.     A failure to adequately assess risk of harm – Poor record keeping and a failure to read electronic records meant that important information was not considered at a Multi-Disciplinary Team (“MD T”) ward round on 6 April 2021. The MDT arrived at a conclusion that Mr Charles’ risk of self-harm was “no risk”. A psychologist’s assessment on the clinical record that assessed Mr Charles risk of self-harm as high on 31/3/21 was neither read nor incorporated into the MDT discussion.

2.    A decision to reduce observation frequency made by the MDT on 6/4/21 was not supported by the Trust Policy guidance which indicated that enhanced observations were appropriate.

3.    A failure to ensure that a treatment plan was followed – observations between 16.00 and 17.00 on the day of Mr Charles’ death were suspended by the ward shift co-ordinator. The decision meant all patients subject to general observation on the ward were ignored.

4.   Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked ” and did not follow policy, specific issues include;

• A ward emergency bell was not sounded.
• An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles.
•  A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination.
• Duty doctors were not called promptly.
• Oxygen administration was delayed.
• An on-site defibrillator was not used by staff.
• Staff could or would not provide a clear and relevant history to paramedics.

5.    The credibility of evidence provided by Trust staff.

• Two Trust witnesses declined to answer questions put to them regarding whether their observation records were truthful.
• Observation records appeared to have been created utilising a “cut and paste” function.
• Records often inaccurately recorded the prescribed frequency of observation.
• Factually inaccurate entries were made in the record following Mr Charles’ death. On 11 April 2021 an entry stated that Mr Charles was, “Awake in his bedroom sitting on his bed (sic)” at 07.21. On 12 April two entries made at 9.48 and 11.40 recorded that Mr Charles’ was alive and well. Senior Trust witnesses characterised these entries as dishonest.

6.    Governance process failings.

• A datix incident report created on the evening of 10 April 2021 by a senior nurse and Modern Matron contained misleading information that suggested that emergency response policies were followed when in fact they were not.
• The Datix failed to mention that observations had been suspended by the shift coordinator, a fact that was understood at that time. This obvious and significant piece of information that should have been escalated through the Trust governance team for action.
• The Trust 72 hour report was written by the Modern Matron and was signed-off by an integrated care director on 15 April 2021. This document also failed to identify or escalate the significant issue of the suspension of observation at 16.00 on 10 April 2021.
• The Trust SI report presented to the inquest failed to address the poor risk assessment or inadequate datix & 72 hr reports.