The imaging demonstrated extensive intraperitoneal and extraperitoneal blood, likely as a consequence of the surgery. Following a conversation with a vascular surgeon it was determined that Mrs Booker required embolisation of the bleeding vessels. However, there is no out of hours interventional radiology at Dorset County Hospital. Therefore, Mrs Booker was transferred to the Royal Bournemouth Hospital for the embolisation of the bleeding vessels by interventional radiology. Following the embolisation, she initially stabilised, but deteriorated again on 24 February and died on 24 February 2023.

Matters of Concern

• During the inquest evidence was heard that:
• There is no out of hours interventional radiology at Dorset County Hospital and that patients requiring this potentially urgent and life-saving intervention that live in the West of the County require transfer to the Royal Bournemouth Hospital for treatment.
• Because of the lack of out of hours interventional radiology at Dorset County Hospital, patients in the West of the County requiring such an intervention must be transferred to the Royal Bournemouth Hospital. This exposes these patients to a potentially considerable and significant delay in the provision of urgent and life-saving treatment, which, in turn, exposes them to an increased risk of death.

1. The two reports from HEM Clinical Ultrasound Ltd on 28 June 2021 and 1 July 2021 and any images associated with the reports were not provided to any of the deceased's treating clinicians. Only the second report from 1 July 2021 was sent to her General Practitioner and not the first report from 28 June 2021. Neither report was uploaded to her clinical notes at Medway Maritime hospital or Maidstone hospital. Had the images and the reports been available to her treating clinicians then a more urgent referral would have been warranted by her General Practitioner and she may have been investigated and treated at a much earlier stage.
2. The court heard that most of Kent have a system whereby imaging taken can be seen at more than one Trust and is even linked to tertiary referral centres in London. The system used was referred to as the PACS system. Clinicians told the court that they could look up images for their patients taken at another hospital and this would impact on their decision making for a patient. Images taken in the community by private providers are not uploaded to the system but can be requested however this relies upon knowing that there were any images to access in the first instance.
3. The managing partner at HEM Clinical Ultrasound Ltd gave evidence that she had been requesting that the imaging they took be made available on the central system. She was unable to explain why this had not been requested or set up or commissioned by the Integrated Care Board. All gave evidence that the lack of imaging being available meant that issues could be missed.

• During the course of the Inquest the jury heard evidence about the difficulty in information being transferred over from Mr Finlayson’s GP surgery system, which uses SystmOne to the prison system (also SystmOne). The evidence was that information was not able to be freely shared between the two and it meant that there was a delay in healthcare staff in the prison accessing relevant information about Mr Finlayson’s long term health issues as well as  contact  with  his  GP  as  recent  as  a  week  before  going  in  to  prision.
• Although there is evidence that the functioning of SystmOne has improved since his death there remains an issue with the interaction between SystmOne and other medical databases used in England and Wales. SystmOne appears to be the preferred system for many prisons and detention centres but  there are still many GP surgeries that use other systems.
• The coroner heard evidence that if someone goes to prison and is linked to a surgery that uses another system (like EMIS) the notes have to be printed and scanned on to SystmOne and key information has to be input onto someone’s record by hand.
• There is concern about the potential delay this process could cause and that key information could be missed by virtue of these systems not communicating with each other. The coroner heard evidence as to the importance of someone’s medical history being available for those within the prison setting to assist with careplanning and the provision of appropriate care and in my opinion, there is a risk that future deaths could occur unless action is taken to make the transfer of this information more efficient.

1. At times of high pressure and business, the paediatric nursing complement is insufficient in the Emergency Department. There are inexperienced paediatric nurses trying to manage a very high workload, without senior nurse support to try and increase staffing levels on a shift. The Facing the Future (RCPCH) standards for levels of paediatric nursing are not met.
2. Handovers and key conversations between staff, both nursing and medical staff, in ED and with paediatric staff are not routinely documented, and outcomes from handovers and escalations do not result in clear action plans and allocated tasks The repeated serious infections, including with an unusual organism, suggested the possibility of an immune deficiency, but no specific condition was established.  

The system for recognising an ill baby in paediatric ED is not robust – from the point of attendance, through timely triage, timely escalation, and joint assessment by senior ED and paediatric staff.

The Trust’s Patient Safety Review identified the following concerns:

• When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues.
• No care coordinator was appointed owing to a shortage of staff.
• The Trust had and continues to have vacancies at consultant leve.
• The family was wrongly advised the Trust was not commissioned to treat OCD.
• The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP.
• Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year.
• In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available.

The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area. The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.

The Coroner heard evidence that in or around October 2022 a new computer system was introduced into the Emergency Department of the University Hospital of North Durham. The provider of the new system is Cerner. Cerner is now owned by Oracle Corporation.

The Coroner heard evidence that the previous software in use in the Emergency Department included a “RAG rating” system, which ensured that the acuity of the patients was easily identifiable by looking at a single page on a display screen. The Coroner heard evidence that the new Cerner software did not include such a system. Instead, the Cerner software has symbols next to patient’s names that, when clicked on, provide an indication of the level of acuity of the patient, but not a clear indication at first glance.

In summary, the Coroner was told that the previous RAG rating system was an effective tool in quickly identifying patients requiring urgent oversight by senior clinicians, especially when the Department was under extreme pressure. It is the Coroner's view that, especially in times of extreme pressure on the Emergency Department, a quick and clear way of identifying the most critically ill patients is an important tool that could prevent future deaths. The Coroner was told that concerns about the absence of a RAG rating type system had been raised by a number of clinicians, but that the response, thus far, had been that the new system does not have that functionality.

1. The inquest heard evidence that a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual and that private beds were being used on a regular basis due to a shortage of NHS beds. The inquest heard that this meant that there were a number of consequences as a result all of such placements which could as in Ms Khan’s case impact on a patient and increase the risk they presented. In particular:

• A family could not easily stay in contact and visiting was almost impossible. This meant a patient felt more isolated and their family could not provide information effectively to the treating clinicians.
• Where a non-NHS bed was being used or an out of trust bed was being used notes were not easily shared as different electronic systems were used.
• Out of area trusts/private providers would not be familiar with local arrangements to support discharge and had to rely on local trust teams to put plans in place which could as in this case lead to less effective communication. 

2. There was evidence from her family that her deterioration was in part due to her going through the menopause and that had there been better awareness of this as a factor in mental health deterioration for some women and better support in place, interventions could have taken place at an earlier stage and been more effective.

3. The inquest heard that due to its size the mental health trust covers a number of areas. Each area has its own systems and pathways. Lack of understanding of these pathways by coordinating teams meant that patients were not being moved onto the correct pathway for care. The inquest heard that this was compounded by a lack of awareness by the Trafford HBTT of the local pathway for a patient such as Ms Khan and the need for a clear discharge plan to be in place that was understood by all those involved in a patient’s care including her family and mental health care workers.

1. Robust real-time statistics.
2. Categorisation of deaths.
3. Variations in writing reports.
4. Variations in responding to reports.
5. Research using coroner reports.

This has now been published: https://committees.parliament.uk/writtenevidence/127982/pdf/

During the course of the evidence it was identified that:

• There was no Datix raised by anyone when the error (Mr Ithell being lost to follow up) was identified, either at the time of the appointment on 22 October 2022 when the error was identified or at any point thereafter;
• There has been no investigation by the Health Board into how Mr Ithell came lost for follow up after his appointment on 5 November 2021;
•  There have been no assurances as to what, if any, changes and learning have been identified other than a tracking system for PSA monitoring;
• Evidence was heard at the Inquest that time restraints on hospital staff had meant that Datix was not completed and that the system was not user-friendly. 

The coroner has raised a number of Prevention of Future Death reports with the Health Board previously around investigation processes. The coroner remains incredibly concerned that where matters are not raised in accordance with internal Health Board processes that assurances given to her previously in Prevention of Future Death Reports cannot be supported. Furthermore, the coroner is concerned that Datix reports will not be raised if time constraints prevents such, where the Health Board themselves often identify the Datix reporting system as the initiation of governance / investigation processes.

Information contained on the NCIS is prepared by, and belongs to, the respective coroners court from each of these jurisdictions.

The NCIS core data set was agreed upon by all participating jurisdictions at the establishment of the NCIS. The NCIS Unit monitors the provision of information from coroners courts against the core data set.

Learn more about data sources and classifications structures used to organise the NCIS data, how they manage data quality, access system manuals and explanatory notes, and read about system updates. Access operational statistics about case closure, document attachment and ICD-10 code inclusion to assist in interpreting search results.

• Availability of ambulances to carry out transfers in a timely manner, in urgent cases, between NHS Hospitals and in responding to 999 and 111 calls in the community.
• Confusion as between ambulance and hospital staff and a lack of clarity in the purpose of and process for the categorisation of transfers (particularly in urgent situations) between NHS hospitals.
• The suitability of the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver such an approach are inadequate.
• Adequacy of the action plan provided to the court in addressing the concern at (a) above and that of ambulance attendances to 999 and 111 calls; the plan is generalised, lacking detail and any means of measurement of progress.
•  Evidence received at Inquest identified waits for ambulance attendance of between 5-6 hours on the evening of 9th/10th December 2022. This, in circumstances where the call relating to Mr. KING had been categorised as a category 2 response. In Mr. KING’s case he was exhibiting symptoms of having suffered/was suffering a heart attack.
•  In Mr. KING’s case he had arrived at hospital been triaged, assessed and arrangements for urgent lifesaving care made by competent emergency clinicians in conjunction with experts from the regional cardiac unit. This included the requirement for an urgent transfer to the regional cardiac centre. A request for an emergency transfer from West Suffolk Hospital to The Royal Papworth Hospital was subject to further computer algorithm-based triage by the ambulance service. This resulted in a several hour delay to Mr. KING’s transfer, notwithstanding the protests from competent clinical staff in the Accident and Emergency Department at West Suffolk Hospital.
•  The circumstances of this case raise concerns about the NHS approach to centralising exigent care in regional centres (such as the Royal Papworth Hospital for cardiac conditions) if the means to deliver the approach are inadequate. 
• East of England Ambulance Service provided evidence to the Inquest, including a Report concerning its response. This plan is generalised, lacking detail and any means of measurement of progress and is inadequate in addressing the concerns raised at the Inquest.

Mrs Robert's family were told on several occasions that the nursing team did not have time to change her dressings. On 17 May 2023 a nurse did not attend to care for Mrs Roberts due to demands upon the District Nursing Team. The team offered instead an out of hours visit that would have disturbed Mrs Roberts and her family from sleep and so this was not accepted.

The Coroner noted that there were ongoing staffing issues within the District Nursing Team and that though a number of steps had been taken to address the issues identified by Mrs Robert’s case, there remains residual staffing shortages in the District Nursing Service the Trust is unable to resolve without a change of approach nationally.

• The Trust investigation was materially incomplete and there was a lost an opportunity to understand concerns of the Family, acknowledge errors and learn lessons from the circumstances of the death.
• The lead investigator did not report on material issues as to how Morgan-Rose was observed on the ward and the report was significantly delayed.
• The investigation did not sufficiently escalate concerns about staff observations, which were shown by CCTV footage to have been recorded incorrectly.
• The investigation did not sufficiently look into security issues raised by this case.

The Coroner also raised the following matters of concern in relation to this case:

• There was a lack of clarity as to whether patients were permitted or not to have belts on Chelmer Ward, relating to the potential risk of self-harm.
• Morgan-Rose attempted to secure unescorted leave on the morning of her death, her Responsible Clinician had only authorised escorted leave. This was not escalated to the nurse in charge and the Responsible Clinician was not informed.
• Evidence was heard that an Oxevision alert is triggered if a person is in the bathroom for more than 3 minutes and staff are required to complete an in-person check. Morgan-Rose was left in the bathroom unobserved for approximately 50 minutes. It was not clear from the evidence how the Trust proposes to ensure compliance in respect of this duty.
• The quality of record keeping was acknowledged to not be appropriate by nurses and senior staff during evidence, yet it had been signed off.
• Observations sheets for vulnerable detained mental patients were signed off by nurses in charge as being appropriate despite an absence of any recorded therapeutic engagement.
• There were omissions in the recording of food and fluid charts required by the Responsible Clinician for a patient who was losing weight with a diagnosis of Body Dysmorphic Disorder. The Responsible Clinician’s evidence was that the absence of appropriate food and fluid charts for other patients was an ongoing issue on Chelmer Ward that had been raised with nursing staff.
• Staff entries in patient observations sheets should have given rise to a concern that some staff may have been using Oxevision not just as an adjunct to face-to-face observations, but instead of them. This remains a concern.

She stated that a previous incident in which a similar concern had been raised, which had led to provision of an emergency GP phone number, that can be used by the clinical teams at South Warwickshire University NHS Foundation Trust, which is manned 24 hours a day and is prioritised over other calls. However she noted that the Cardiology team had not been aware of this, nor did they have the telephone number.

The Coroner also noted that Mr Guillaume was not discussed at the Multi-Disciplinary Team meeting with UHCW on 9 June 2023, as the referral had not been completed. She said that had the referral been completed, the team at UHCW could have prioritised the patient’s transfer.

Matters of Concern

• Mrs Gladstone had been prescribed warfarin for a number of years and her levels were regularly checked by the Anticoagulation Service. On 20 December 2020 Mrs Gladstone was prescribed tramadol for low back pain, with a further prescription on 4th January 2021.
• On 21 December 2020 her INR was found to be 3.3. When she was admitted to Lister Hospital on 6 January 2021 tests showed her INR to be 11.6. Immediate action to reverse this was taken. The evidence showed that this level of blood thinning was likely to cause significant bleeding including in the brain. The cause of death was bleeding in the brain
• A comment from the Anticoagulation Service in relation to tramadol reads “Known interactor although this is not listed in the BNF, from experience we have seen that this can increase the INR.” There was nothing to warn the prescribing doctor of any possible interaction. The coroner found on the balance of probabilities that an interaction between tramadol and warfarin had caused this dangerous, and in the event fatal, INR level to develop.

1. Despite recognising Mr Malone needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT’ RCA report identified no remedial action.
2. The Patient Safety Manager gave evidence that the lack of psychiatric bed capacity remains an ongoing problem and has not been resolved, and there is a genuine risk of the same problem with another patient in the future.
3. There was an exceptional process, which required a considered decision at a high level, to make a bed available through identifying someone currently occupying a bed space to be discharged. In my view, this process is unsatisfactory as it creates a different set of risks around the patient being discharged, and amplifies the chronic shortage of beds.
4. There was reference to two preceding Regulation 28 Reports to Prevent Future Deaths that focussed on the chronic lack of mental health resources in Birmingham and Solihull. In relation to the specific issue of a lack of psychiatric bed capacity, in the case of Peter Fleming (no bed was available in August 2022) BSMHFT’s response (September 2023) referred to their response in the earlier case of Leroy Hamilton (no bed was available in December 2021). This response (April 2023) stated more resources had been obtained and a collaborative plan had been implemented with NHS Birmingham and Solihull Integrated Care Board.
5. The issue of adequately funding psychiatric beds is a local and national issue. Locally, BSMHFT require their commissioners to provide the necessary funding.
6. The coroner's concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate. Whilst some action may have been taken it is insufficient to resolve the problem. It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken.

1.  There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care- coordinator. The lack of care-coordinators, mental health inpatient beds, ‘place of safety’, and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
2. BSMHFT utilises self-contained specialist teams. The deceased was treated by (a) crisis team/home treatment team, (b) community mental health team, and (b) psychiatric liaison team. The evidence demonstrated communication between the specialist teams was not effective and this caused delays. For example, the psychiatric liaison team nurse that reviewed the deceased updated the community mental health team. However, the GP could not prescribe the deceased’s medication in October 2022 because it had not been approved by the community mental health team consultant via an ESCA and the deceased went without his medication. The deceased’s GP had to contact the community mental health team directly notwithstanding the psychiatric liaison nurse’s involvement. The deceased cited this delay as making his mental health worse shortly before his death. The concern is communication between the specialist teams is not effective enough. BSMHFT’s RCA action plan is to seek assurance from the CCG/ICB that communication between the specialist teams is being strengthened. The concern is that this does not go far enough and there should be consideration of a formal process or policy.
3. Carbamazepine management was proposed in 2012 to manage the deceased’s mental health however this was not picked up by his GP and was only noted by a BSMHFT consultant in August 2022. Therefore, the deceased went 10 years without this medication. BSMHFT could not explain at the inquest why this omission had not been identified sooner. BSMHFT’s RCA action plan does not have any action to avoid a repeat occurrence. The concern is this issue indicates a problem with process and systems and further consideration is required to avoid a repeat occurrence.
4. The deceased’s GP raised concerns that different health organisations use different digital systems that do not communicate with each other. Further, GPs often do not get important patient updates from primary care organisations for many days or weeks. The concern is communication between different health organisations is not as effective as it could be and important information is being missed, and consequently a material delay in treatment is occurring.
5. The deceased’s GP raised concerns that current resources do not allow GPs to pro- actively check patients are collecting prescribed medication due to excessive patient lists. The concern is that this is a consequence of lack of resources at a national level.

• East of England Ambulance Trust  (EEAST) were telephoned at 19.30 hours to request an ambulance to transport Mrs Ruse to the High Dependency Unit. This was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average time of 18 minutes.
• There were no emergency ambulances available to assign to this call due to high call demand.
• An ambulance did not become available until 20.54 hours and arrived on scene at 20.57 hours, by which time Mrs Ruse had deteriorated further and had been taken back into theatre. EEAST staff did wait (exceeding the period of their shift) and Mrs Ruse was taken to the High Dependency Unit at 22.42 hours. It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients. However evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur.

This Prevention of Future Deaths report raises similar patient safety concerns about delayed transfers from a Spire Norwich Hospital to Norfolk and Norwich University Hospital NHS Foundation Trust to the two reports below. These three patients covered by these reports all died within a nine-month period.

• Prevention of Future Deaths report: Barbara Hollis (3 October 2022)
• Prevention of Future Deaths report: Geoffrey Hoad (13 September 2023)

• East of England Ambulance Trust (EEAST) were telephoned at 19.51 hours and the caller said that immediate intervention was needed. The incorrect pathway was then followed and it is understood action has been taken in this respect.
• The call was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average response time of 18 minutes.
• At 21.17 hours a second telephone call was made to EEAST. An ambulance was on scene at 21.27 hours.
• There were no emergency ambulances to respond to the initial 999 call due to high demand on the service.
• It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients.
• However, evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur.

This Prevention of Future Deaths report raises similar patient safety concerns about delayed transfers from a Spire Norwich Hospital to Norfolk and Norwich University Hospital NHS Foundation Trust to the two reports below. These three patients covered by these reports all died within a nine-month period.

• Prevention of Future Deaths report: Geoffrey Hoad (13 September 2023)
• Prevention of Future Deaths report: Christina Ruse (3 October 2022)

For Government departments, agencies, and private providers:

1. All should ensure that their approach to the PFD process is open, non-defensive and that the public interest in preventing future deaths is prioritised over reputational considerations at every stage. For example, lawyers should be specifically instructed not to take an adversarial approach to the making of a PFD report, and instead to neutrally present the evidence in order to assist the coroner. 

2. All should ensure that they approach the PFD process with full candour and proactively provide all relevant information at the earliest appropriate stage. 

3. The Ministry of Justice (MoJ) should adequately resource the Chief Coroner’s Office to produce a yearly review of PFD reports for custody deaths. This should aim to identify themes and trends, and report on the timeliness and quality of responses, as part of the Chief Coroner’s role under existing guidance.3

4. The MoJ should provide dedicated funding to the Chief Coroner’s Office to enable it to centrally record the conclusions of inquest juries, even where no PFD report is issued, and publish them online for easy referral in the same way that PFD reports are currently published. 

5. The Department of Health and Social Care (DHSC) should give serious consideration to the creation of an independent body for investigating deaths of those formally or informally detained in mental health settings. This would remove the anomaly between the investigation of such deaths and those of persons in other detention settings andensure that coroners consistently have the benefit of high quality evidence regarding the circumstances of such deaths for the purposes of the inquest.

6. Recipients of PFD reports relating to deaths in custody should hold a “post-inquest learning review” meeting following the conclusion of an inquest, attended by the key persons who participated in the inquest. This will help to ensure both an efficient and fully informed response to PFD reports and the formulation of an appropriate action plan to take forward necessary learning.

7. Recipients of PFD reports should ensure that their responses are timely, high quality,case-specific, and fully informed by the inquest evidence and findings. Where the response relays that action will be taken, actions should be identified in precise termsand with precise timelines. Where no action is to be taken, a clear, detailed and respectfully worded explanation should be provided to enable the coroner, family, and wider public to understand the basis for the decision. Recipients should ensure that their responses recognise and reflect the significance of PFD reports to bereaved families, with consideration given to how families can be kept informed and where appropriate consulted on the action plan. 

8. All should ensure PFD reports are shared ‘horizontally’ with relevant equivalents across the country – for example, other police forces, prisons, and mental health trusts –particularly where there may be scope for national learning, to ensure opportunities tomake change across different custody areas are not missed. 

9. Leaders of local custody bodies, such as prison governors, should consider adopting the approach of Milton Keynes Together Safeguarding Partnership and hold periodic meetings of representatives from all custodial settings to review relevant PFD reports, with participation, where appropriate, of local coroners.

10. Government should consider what enhanced role independent bodies might play in auditing, following up on, and reporting on PFD reports, and this could include establishing a new body for this purpose. More effective oversight of the sharing, use, and implementation of matters of concern in PFD reports is needed.

For the Chief Coroner and his Office:

11. The Chief Coroner should consider supplementing his guidance on PFD reports to further address when it may be appropriate, in compliance with the statutory requirements, to make interim PFD reports and the importance of doing so, in particular where a coroner is of the opinion that there is an urgent need for action to prevent future deaths. 

12. The Chief Coroner should consider supplementing his guidance to advise coroners on the importance of ensuring relevant evidence is provided at a sufficiently early stage, inparticular where coroners consider there may be a need for urgent action. The guidance should remind coroners that previous PFD reports and evidence of ‘near-miss’ incidents may be relevant and important.

13. The Chief Coroner’s Office should review and consider expanding the list of organisations which should receive PFD reports on deaths in state custody (found at paragraphs 56 and 57 of the guidance on PFD reports) to ensure more comprehensive coverage of relevant bodies, organisations, and departments. This should be circulated to all coroners and used in training on PFD reports. The IAPDC could assist with ensuring this list is up to date and comprehensive.

14. The Chief Coroner’s Office should ensure that its online database of PFD reports is fully searchable by thematic areas and location, and that deaths in detention (particularly under the Mental Health Act 1983 (MHA) are readily identifiable. Consideration should be given to tagging reports according to the deceased’s protected characteristics to help better identify and understand issues of disproportionality. For other bodies with a key role to play in preventing custody deaths:

15. The Ministerial Board on Deaths in Custody secretariat should send PFD reports on deaths in custody to the House of Commons Justice, Health, and Home Affairs Select Committees, which should consider taking evidence and reporting on significant themes.

16. All organisations which scrutinise places of detention should make explicit use of PFD reports to inform their investigations, inspections, and thematic reports and bulletins, including monitoring and reporting on progress made against responses to PFD reports by services and agencies. They should work with the Chief Coroner to agree protocols to work together and share learning.

17. The Ministerial Board on Deaths in Custody (MBDC) secretariat should continue to review and distribute PFD reports relating to death in custody to MBDC members for the purpose of sharing learning, and consider involving all relevant agencies and partners who would benefit from additional learning across all places of state detention. Issues of significant wider concern arising from recent PFD reports should be discussed at MBDC meetings. 

18. The Judicial College should work with the Chief Coroner to deliver mandatory training to coroners on the purpose, process, publication, and distribution of PFD reports, as well as the role of independent scrutiny bodies, incorporating the perspective of bereaved families.

Read the full report via the link below. 

• Mr Whatling was not eating and drinking very much. A food and fluid chart was not fully completed.
• Emergency services were not called on 8 April 2023 when Mr Whatling scored NEWS2 7 as required.
• The evidence so far revealed is that 111 call taker was not made aware Mr Whatling had scored NEWS2 7.
• Mr Whatling’s observations were not taken hourly as required.
• Some of Mr Whatling’s observations were recorded on a piece of paper and were not logged in his Care Records.
• The Manager only became aware of gaps in the records following concerns raised by the family.
• There is no evidence that any action has been taken following Mr Whatling’s death.

1. The medical professionals who work in a hospital emergency department are routinely expected to do so when the OPEL 4 applies, a recognition they are performing their roles when the hospital is “unable to deliver comprehensive care, and patient safety is at risk”. Such pressures may serve to leave the Emergency Department unable to triage patients such as Derek, and have no time to notify the doctors expecting his arrival (in this case doctors on the Surgical Assessment Unit) who are consequently left unaware that a patient has in fact arrived, all of which serves to place vulnerable patients such as Derek Pedley at serious risk.
2. There is a risk that the pressures on hospitals become so significant they are used as a default explanation for levels of patient care that fall below what they would wish to deliver. The coroner found that the hospital Trust did not seek to do so in this case, but it seems there is a risk this could happen. The pressures are indeed significant, but ultimately this case involves a 90 year old man with what appears to be an acute medical problem finding himself attending his local emergency department, not being spoken to / triaged by a medical professional for almost two hours, and dying by the time  he is called for. There is a clear risk that puts patients at risk and it would be remiss of me not to raise it.
3. Finally, it is relevant to point out that Derek had not moved for some time before a medical professional called for Derek. The coroner formed the view that there had been a reluctance on his friend’s part to request assistance due to the pressures staff were clearly under, but also because he had already handed in Derek’s paperwork and was expecting some assistance imminently which did not arrive. It is felt that Derek and his friend thought as they knew doctors had discussed his case with his GP and that his attendance was expected they did not need to raise a concern until it was too late. In actual fact, such are the pressures Emergency Departments are working under, this may not be the case. Unless GPs are provided with a realistic picture about how quickly their patients may be  seen once they arrive at hospital (even if they have been in communication with the hospital doctors) their patients may arrive at hospital expecting to be seen quickly, when in reality this may not be the case particularly when the department is under significant pressures.