Recurring concern

Inadequate informed-consent processes for medical treatment

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First reported 1 Jul 2014•Latest report 28 Dec 2025

Definition

What this concern includes

Includes failures of medical-treatment consent processes, including initiation, information about material risks, time for consideration, consistency of procedure, assessment of consent and documentation, where the failure is directly tied to obtaining valid informed consent.

Not included

  • Excludes legal-status or detention transfers that do not concern consent to medical treatment.
  • Excludes general communication, training, documentation or staffing deficiencies unless they are directly tied to the medical-treatment consent process.
  • Excludes clinical assessment or treatment-selection failures that do not concern obtaining or recording informed consent.
Reports
31

Distinct published reports

Individual concerns
37

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
56

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care7
Care Quality Commission2
General Medical Council2
Mid Yorkshire Teaching NHS Trust2
Royal College of Radiologists2
University Hospitals Sussex NHS Foundation Trust2
Aden Court Care Home1
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Association Of Anaesthetists (Great Britain & Ireland)1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Barts Health NHS Trust1
Birmingham Women'S and Children'S NHS Foundation Trust1
Bradford Teaching Hospitals NHS Foundation Trust1
British Society For Dermatological Surgery1
Circle Health Group Limited1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. West Yorkshire Eastern

    AI-generated summary

    Ms Samantha Jade Shillito · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ms Samantha Jade Shillito was significantly unwell when admitted to hospital and underwent an ascitic tap procedure that perforated an artery, causing intra-abdominal bleeding. She deteriorated over the following weekend without medical review or further investigations and died on 27 February 2022. Concerns included missed opportunities to respond to her deterioration, inadequate information about the risks of the procedure and shortcomings in communication with her family.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide adequately informed consent for ascitic tap procedures

    Wider context from the report

    “(3) The practice at the hospital was to obtain verbal consent to the procedure from the patient in the minutes before it took place. A consultant radiologist acknowledged that the risk of death was not mentioned to Ms Shillito. It is questionable whether this can be considered to be a patient’s informed consent when the risks outlined are not reliably established, are not explained and the patient is not asked to sign a document. If there is a risk of death, irrespective of its rarity, the patient is entitled to be informed. This concern is heightened when one considers the patient’s medical condition and their likely emotional state, in circumstances which allow no time for reflection or discussion with other family members. It appears that no leaflet describing the ascitic tap procedure and the associated risks has been provided either by the Royal College of Radiologists or the hospital. ”

    Source location

    Ms Samantha Jade Shillito · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue supporting clinicians and patients to assess and discuss ascitic-tap risks and benefits before procedures.

    Verbatim wording from the response

    “Therefore to address this concern fully, we welcome any advice from the Royal College of Radiologists (also issued with this regulation 28). In the interim, however, we continue to work with our clinical teams to support appropriate risk/benefit assessments by the healthcare professional and consideration of these risks/benefits with patients prior to a procedure.”

    Source location

    Response from Mid Yorkshire Teaching NHS Trust
    Page 3 · response
    Published 8 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review patient-safety leaflets against relevant professional guidance to support informed shared decisions about ascitic-tap care.

    Verbatim wording from the response

    “With regard to patient information leaflets, we do use patient information leaflets for many procedures but not universally for those procedures that are perceived to be very low risk. I acknowledge that in my own exploration of this concern I have identified several NHS Trusts which have information leaflets for a diagnostic ascitic tap procedure (needle removal of a small amount of fluid) and/or the more invasive paracentesis (usually implied as insertion of a drain to remove larger volumes of fluid). None of those leaflets specifically mention the risk of death. We will, however, review our patient safety leaflets in accordance with relevant guidance from professional bodies such as the Royal College of Radiologists and British Society of Interventional Radiology to”

    Source location

    Response from Mid Yorkshire Teaching NHS Trust
    Page 3 · response
    Published 8 December 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The GMC’s comprehensive consent framework provides sufficient current principles for obtaining valid informed consent in radiology.

    Verbatim wording from the response

    “The RCR archived its previous document Standards for patient consent particular to radiology (Second edition) in 2021, following the publication of the General Medical Council’s (GMC) updated guidance on decision making and consent. We fully endorse the GMC’s framework, which provides comprehensive and up-to-date principles for obtaining valid informed consent across all areas of medical practice, including radiology.”

    Source location

    Response from The Royal College of Radiologists
    Page 2 · response
    Published 8 December 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Producing patient information leaflets for individual procedures falls outside the RCR’s role as a professional standards body.

    Verbatim wording from the response

    “Both BSGAR and BSIR have confirmed that they do not produce a specific patient information leaflet for ascitic drainage and the RCR does not produce patient information leaflets for individual procedures. This reflects our role as a professional body that sets and promotes standards of practice, rather than as a direct provider of patient-facing materials. However, BSIR has noted that the Cardiovascular and Interventional Radiological Society of Europe provides a general leaflet on fluid and abscess drainage procedures, which includes information on bleeding risks. BSIR also notes that there are numerous high-quality leaflets freely available through NHS trusts and related professional organisations. These typically include clear, evidence-based descriptions of procedure risks and are suitable for adaptation or local use.”

    Source location

    Response from The Royal College of Radiologists
    Page 2 · response
    Published 8 December 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Trust cannot definitively quantify ascitic tap risks because specific published evidence is absent, a national or international problem.

    Verbatim wording from the response

    “As an organisation that provides healthcare, we rely on various sources of information to enable us to quantify the risks of any procedure. The majority of this information is sourced from guidance issued by specialist societies, royal colleges, or developed through literature evidence base/local audits etc. In the instance where there is an absence of specific quantifiable risks, best practice is to inform patients of potential complications with indicative likelihoods of these occurring. For an ascitic tap it is felt to be very low risk based on the experience and judgement of the health professionals involved. Decisions to proceed with an intervention would also be balanced against the risk of not proceeding with an intervention”

    Source location

    Response from Mid Yorkshire Teaching NHS Trust
    Page 3 · response
    Published 8 December 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Verbal consent remains acceptable for many low-risk procedures because written consent is impracticable in every instance; patient leaflets are not universal.

    Verbatim wording from the response

    “As you are aware, the process of consenting a patient for a procedure is an ongoing one that starts with a conversation with the patient about treatment options and culminates with the signing of the consent form. The form itself is merely the final “ok” from the patient to go ahead after a number of steps have taken place over a length of time, to obtain fully informed consent from the patient.”

    Source location

    Response from Mid Yorkshire Teaching NHS Trust
    Page 3 · response
    Published 8 December 2023

    Open published response
  2. West Yorkshire (Eastern)

    AI-generated summary

    David Barnet WILSON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David Barnet Wilson was admitted to hospital with suspected colitis and underwent a flexible sigmoidoscopy, during which a recognised colonic perforation occurred. He died at Pinderfields Hospital on 31 December 2022; concerns included inadequate explanation and tailoring of procedural risks, failure to mention the risk of death, and obtaining consent while he was under morphine sedation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Obtaining consent signatures while patients are under morphine sedation

    Wider context from the report

    “(4) The Consent Form did not identify those clinicians involved in discussing the decision with him, save for ████████ who obtained his signature at a time when he was under the influence of morphine sedation. ”

    Source location

    David Barnet WILSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to identify clinicians involved in consent discussions

    Wider context from the report

    “(4) The Consent Form did not identify those clinicians involved in discussing the decision with him, save for ████████ who obtained his signature at a time when he was under the influence of morphine sedation. ”

    Source location

    David Barnet WILSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Refresh the consent policy to require documentation of patient-specific increased risks, earlier discussion of death risk, and consideration and documentation of capacity.

    Verbatim wording from the response

    “As it is proposed to include risk ranges, to a certain degree these will inherently account for varying medical histories and co-morbidities of patients. But in instances where a specific risk is greater due to a particular patient’s unique circumstances, this medical advice will be clearly noted. We will also update and strengthen our consent process through our internal policy to reflect this requirement (see below).”

    Source location

    Response from Mid Yorkshire Teaching NHS Trust
    Page 2 · response
    Published 12 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with clinical teams to ensure patients’ capacity to consent is considered, taken into account, and properly documented.

    Verbatim wording from the response

    “In relation to the capacity to consent, the Trust will work with clinical teams to ensure that as part of the consent process, the question of a patient’s capacity – regardless of the circumstances – is considered, taken into account, and properly documented. The issues surrounding capacity will also be further highlighted in the Trust’s internal policy (see below).”

    Source location

    Response from Mid Yorkshire Teaching NHS Trust
    Page 3 · response
    Published 12 June 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Time and resource constraints make listing all staff involved throughout a patient's consent process impracticable.

    Verbatim wording from the response

    “Ideally the final consent form would list all MYTT staff who have been involved throughout the entire consenting process of the patient for a particular procedure. Unfortunately, time and resource constraints make this suggestion impracticable for implementation by the Trust.”

    Source location

    Response from Mid Yorkshire Teaching NHS Trust
    Page 3 · response
    Published 12 June 2023

    Open published response
  3. West Yorkshire (Western)

    AI-generated summary

    Dilys Greta Etchells · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Dilys Greta Etchells was found after an unwitnessed fall at her nursing home, later diagnosed with fractures of the left tibia and fibula, and subsequently developed pressure ulcers before dying in hospital on 2 July 2021. The report identified concerns about the absence or documentation of fall-prevention measures, delayed medical referral, inadequate care documentation, handover communications, and wound-management procedures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate protocols for consent to medical treatment forms

    Wider context from the report

    “• To review existing protocols governing wound management, completion of admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form. ”

    Source location

    Dilys Greta Etchells · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Train nurses and shift leaders on documentation, care plans, wound management, assessments, body maps, consent forms and hospital-return documentation.

    Verbatim wording from the response

    “In addition, I provided a training session to all the Registered General Nurses and Shift Leaders at Aden Court on 2 July 2021 (see also below). Part of the session covered expectations around documentation and specifically how staff should complete Hill Care’s standard proforma documentation including; admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and return from hospital form. Following the session, all attendees confirmed that they were aware of and understood Hill Care’s policies and procedures in relation to documentation and that they had received training on how documentation must be completed.”

    Source location

    2021-0428-Response-from-HIll-Care-Group_Published
    Page 3 · response
    Published 29 December 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing protocols for wound management and required care documentation are considered sufficient, with compliance monitored through regular audits.

    Verbatim wording from the response

    “There are clear protocols in place within Aden Court in relation to wound management, admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form. As outlined above, I provided a training session for all the Registered General Nurses and Shift Leaders on 2 July 2021. The session covered wound management, completion of admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form to ensure that they were aware of the protocols in place within Aden Court. Compliance is monitored through an ongoing, regular and thorough audit process. I have provided more detail below.”

    Source location

    2021-0428-Response-from-HIll-Care-Group_Published
    Page 7 · response
    Published 29 December 2021

    Open published response
  4. Nottinghamshire

    AI-generated summary

    William DOLEMAN and 3 others · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Four patients died following ERCP-related complications within a six-month period. The concerns included inadequate pre-procedure assessment and patient pathways, insufficient recording of procedure vetting, non-personalised consent, and unclear accountability between professionals for vetting and consent.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of accountability between professionals for consent

    Wider context from the report

    “4. A lack of accountability between professionals for ensuring robust vetting and consent. ”

    Source location

    William DOLEMAN and 3 others · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to personalise consent

    Wider context from the report

    “3. Consent is not personalised, contrary to recommendations made by the ESGE in December 2019. ”

    Source location

    William DOLEMAN and 3 others · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement the redesigned Medway-based ERCP referral pathway with expanded clinical-risk and consent information fields.

    Verbatim wording from the response

    “The following actions have been taken to address this concern:”

    Source location

    2021-0432-Response-from-City-Hospital-Campus_Published
    Page 2 · response
    Published 29 December 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide inpatient information booklets and obtain consent through ERCP endoscopist ward reviews before procedures.

    Verbatim wording from the response

    “It is not currently possible for individual personalised risk to be calculated precisely although there are aspirations for this at some point in the future. It is possible to provide estimates of the relative risk to an individual patient in relation to the population risks and to ensure that this is documented in the patient record. A number of actions to support this have already commenced:”

    Source location

    2021-0432-Response-from-City-Hospital-Campus_Published
    Page 2 · response
    Published 29 December 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Amend patient information and consent forms to document operator experience or supervision arrangements and enhanced individual risk.

    Verbatim wording from the response

    “• Patient information and consent forms will be amended to include a statement that “I understand that you cannot give me a guarantee that particular person will perform the procedure. The person performing the procedure will have appropriate experience or expert supervision”.”

    Source location

    2021-0432-Response-from-City-Hospital-Campus_Published
    Page 3 · response
    Published 29 December 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The described vetting and consent arrangements are expected to resolve accountability between professionals, so no additional action is identified.

    Verbatim wording from the response

    “4. A lack of accountability between professionals for ensuring robust vetting and consent.”

    Source location

    2021-0432-Response-from-City-Hospital-Campus_Published
    Page 3 · response
    Published 29 December 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Precise individualised risk cannot currently be calculated, limiting the ability to personalise ERCP consent precisely.

    Verbatim wording from the response

    “3. Consent is not personalised, contrary to recommendations made by the ESGE in December 2019.”

    Source location

    2021-0432-Response-from-City-Hospital-Campus_Published
    Page 2 · response
    Published 29 December 2021

    Open published response
  5. Worcestershire

    AI-generated summary

    RHIAN EMMA KATE ROSE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Rhian Rose became unwell during a hospital admission for the second phase of medical termination of pregnancy following feticide for trisomy 21. Her condition deteriorated, leading to emergency caesarean section, hysterectomy and cardiac arrest; she died from multi-organ failure and sepsis on 25 November 2019. The principal concerns were insufficient consideration of informed consent and maternal choice regarding mode of delivery, and inadequate guidance on infection risks and delivery options following feticide.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide informed consent discussions and facilitate maternal wishes regarding mode of delivery

    Wider context from the report

    “1) Informed consent and material choice regarding mode of delivery – I am concerned that enough emphasis is not being given to maternal wishes regarding mode of delivery. This issue appears to be a recurring theme in obstetric practice, and I am concerned that the culture in this area appears to still not fully accepting of the principles of informed consent set down in case law of the appeal courts (Montgomery) and in NICE guidance (Caesarean Section) and of facilitating the wishes of pregnant women and holding full and frank discussions about the risks and benefits and the pros and cons of the different options. I am concerned that situations might arise, like it appeared happened in Rhian’s case, where maternal requests are being made for re-consideration of the mode of delivery owing to feelings of physical weakness, pain or developing ill health. Evidence heard at Rhian’s inquest demonstrated that there was very little, if indeed any, recorded (in medical records) discussions held between midwives/obstetricians and Rhian regarding mode of delivery, maternal wishes and risk/benefits of differing management plans. ”

    Source location

    RHIAN EMMA KATE ROSE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Adopt the IDECIDE tool in the maternity information system to support and document informed mode-of-delivery decisions.

    Verbatim wording from the response

    “The IDECIDE tool has already been built into the BadgerNet maternity information system, however NHSX has asked that CleverMed to hold off on making this available to sites in the live BadgerNet mode. NHSX want to ensure other vendors have the opportunity to create a version, and are working on taking the design CleverMed have created into a more generic specification. CleverMed have asked NHSX for a timescale of when they could start a pilot or involve BadgerNet sites however this has yet to be agreed.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 2 · response
    Published 4 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce personalised care plans in the BadgerNotes app for discussion, review and professional authorisation.

    Verbatim wording from the response

    “C) Personalised care plans are being introduced at WHAT in January 2022, this will give women the ability to complete a birth plan within their BadgerNotes app, the plan must be discussed, reviewed and authorised by a Healthcare professional.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 3 · response
    Published 4 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide monthly multidisciplinary maternity training covering human factors, informed consent, Montgomery, balanced counselling and documentation.

    Verbatim wording from the response

    “D) Training at WAHT in maternity is multi professional and this takes place on a monthly basis. Included within this a section is dedicated to human factors, Informed consent and reference is made to the Montgomery ruling and balanced counselling and documentation. This case highlighted the importance of contemporaneous documentation regarding mode of delivery discussions and decisions.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 3 · response
    Published 4 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish and audit a robust process for managing requests for Caesarean Section during labour.

    Verbatim wording from the response

    “E) Following the Ockenden Review, one of the immediate essential actions is for review of management of maternal request for Caesarean Section for both elective cases and during labour. This is a challenge for all maternity units across the country and is a matter being considered carefully by the Royal College of Obstetricians and Gynaecologists (RCOG) and Royal College of Midwives (RCM). The trust performance and progress with this action will be monitored via the Local Maternity & Neonatal System (LMNS) as part of the National Perinatal Quality Surveillance tool. In the first review by NHSEI the trust have received an amber rating for this as we do not currently have a robust audit process for “in labour” requests for Caesarean Section. Our initial action to improve this position would be to develop an achievable process and to appoint an ‘Audit & Guideline Midwife’.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 3 · response
    Published 4 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Appoint an Audit and Guidelines Midwife to support Caesarean-request process development and audit.

    Verbatim wording from the response

    “E) Following the Ockenden Review, one of the immediate essential actions is for review of management of maternal request for Caesarean Section for both elective cases and during labour. This is a challenge for all maternity units across the country and is a matter being considered carefully by the Royal College of Obstetricians and Gynaecologists (RCOG) and Royal College of Midwives (RCM). The trust performance and progress with this action will be monitored via the Local Maternity & Neonatal System (LMNS) as part of the National Perinatal Quality Surveillance tool. In the first review by NHSEI the trust have received an amber rating for this as we do not currently have a robust audit process for “in labour” requests for Caesarean Section. Our initial action to improve this position would be to develop an achievable process and to appoint an ‘Audit & Guideline Midwife’.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 3 · response
    Published 4 November 2021

    Open published response
  6. Plymouth, Torbay and South Devon

    AI-generated summary

    Name not published · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    The deceased had significant comorbidities, including ischaemic heart disease, and was admitted to hospital for a blood transfusion following a diagnosis of anaemia. An endoscopy to investigate blood loss was abandoned, and on the balance of probability her oesophagus was perforated during the procedure; she developed surgical emphysema, deteriorated and died at Derriford Hospital on 11 December 2017. Concerns included discrepancies in consent for endoscopy, failure to perform or address a ‘sip test’ to exclude aspiration, failure to act on a report indicating a possible dangerous complication, and inadequate record-keeping or transfer of records by senior staff.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inconsistent consenting procedures for identical endoscopy treatment

    Wider context from the report

    “(1) There appears to be a significant discrepancy between clinicians on the consenting procedure for the identical treatment of endoscopy. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Move toward procedure-specific consent information and engage external providers to support standardised information for each procedure.

    Verbatim wording from the response

    “Currently the plan of the organisation is to move to procedure specific consent where possible and appropriate. We are looking to engage with external providers who produce consent and procedural information that are specific to particular procedures. In that way, rather than individual clinicians using their clinical discretion as to what to discuss with patients, standardised information is given each time a patient consents, ensuring all material information is given. For those undergoing elective surgery, it also allows more time for patients to read at their leisure the information provided, so they have time to digest and absorb the relevant information before signing to say they would wish to proceed.”

    Source location

    2021-0211-University-Hospitals-Plymouth_Published
    Page 2 · response
    Published 28 June 2021

    Open published response
  7. West Yorkshire (west)

    AI-generated summary

    Allison Louise Bird · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Allison Louise Bird developed a gastro-pulmonary fistula, a recognised but rare complication of bariatric surgery, followed by severe infection and further surgery. Her condition deteriorated after surgery, she underwent emergency surgery on 13 March 2018, and she died on 16 March 2018 despite intensive care support. Concerns included the timing and adequacy of preoperative discussion and consent, monitoring of vital signs, and escalation for clinical review when observations were non-reassuring.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide adequate preoperative discussion and explanation before consent

    Wider context from the report

    “1. There was no discussion/explanation provided to Allison before she underwent planned major thoracic surgery on the 5th March 2018, the explanation given was immediately before she was asked to provide her written consent in the theatre area minutes before surgery commenced, a situation which if repeated causes me concern for a patient being able to appropriately consider the risks associated with proposed surgery and determine if they are willing to consent. ”

    Source location

    Allison Louise Bird · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  8. South Wales Central

    AI-generated summary

    Darren John Goddard · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Darren John Goddard underwent an elective trans-rectal ultrasound of the prostate and subsequently developed sepsis, becoming acutely unwell and dying on 18 April 2019. The principal concerns included delayed recognition and treatment of sepsis, delays in triage, antibiotics, fluids and critical care, and the information provided about sepsis risks and symptoms following the procedure.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Misleading emphasis on flu-like symptoms in TRUS elective surgery consent and information provision

    Wider context from the report

    “(1) TRUS elective surgery ‘consenting’ and information provision (oral and in written format) places a misleading emphasis on flu-like symptoms as adverse effects. ”

    Source location

    Darren John Goddard · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Standardize sepsis terminology and remove “rarely” from the TRUS biopsy consent form.

    Verbatim wording from the response

    “1. Review and provide definite warnings (oral and written) of sepsis when consenting patients to TRUS, and upon their discharge.”

    Source location

    2020-0060-Response-from-Dr-Hopkins-Redacted
    Page 1 · response
    Published 20 March 2020

    Open published response
  9. West Yorkshire (East)

    AI-generated summary

    LEAH LOUISE CAMBRIDGE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Leah Louise Cambridge, aged 29, travelled to Izmir, Turkey, for a Brazilian Butt Lift under general anaesthetic and died during the procedure on 27 August 2018. A post-mortem examination found that fat had entered veins in her body, causing a fat embolism. The concerns included continued UK involvement in BBL procedures, inadequate informed consent, and a lack of regulatory intervention and control.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to obtain informed consent for BBL procedures

    Wider context from the report

    “(2) In order to make an informed decision as to the wisdom of undertaking effective cosmetic surgical procedures such as BBL, it is important that the person involved receive adequate information regarding the mortality and morbidity risks involved. In order to read and absorb such information it needs to be provided prior to any commitment being made or expense incurred. The Inquest into the death of Ms Cambridge heard that she was provided with a substantial quantity of material (some of which was written in Turkish) on the morning of the surgery and required to sign each page. The Inquest found she had insufficient time to digest this complex material, even if she was in a frame of mind to try, shortly before being taken to theatre. My concern is that informed consent is not obtained. ”

    Source location

    LEAH LOUISE CAMBRIDGE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish revised consent guidance with tailored specialty materials emphasising time for patients to consider treatment information.

    Verbatim wording from the response

    “We will be publishing a revised version of the guidance later this year which will place even greater emphasis on giving adequate time for a patient to digest the information and reach a decision about treatment. It will be supported by tailored materials for specialties where we know there are issues with applying the guidance in practice.”

    Source location

    2019-0408-Response-from-the-General-Medical-Council-1
    Page 3 · response
    Published 29 December 2019

    Open published response
  10. Manchester City

    AI-generated summary

    David John Smith · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David John Smith underwent a dual renal transplant involving kidneys from a CMV-positive donor, but the donor’s CMV status was not communicated to him and was incorrectly recorded as negative. He did not receive CMV prophylaxis, later developed CMV infection and ganciclovir resistance, deteriorated, and died on 5 July 2017. The principal concerns were the consent process and failures to communicate and accurately record the donor’s CMV status.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to communicate donor kidney CMV status to the transplant recipient for informed consent

    Wider context from the report

    “1. The consent process – I found that the CMV status of the donor’s kidneys (listed as positive on the Electronic Offering System form) was never communicated to the Deceased for him to consider the risks of proceeding with the transplantation, and for him to provide informed consent. 2 Recording of the CMV status – When the plan for the deceased’s surgery was communicated to the Renal transplant team in an email, this did not include reference to the donor’s CMV status, nor did it attach the relevant EOS form. Consideration should be given to introducing a process in which the EOS form itself is sent onwards to the Renal transplant team to ensure important information such as the CMV status is not missed by the treating clinicians. ”

    Source location

    David John Smith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Strengthen transplant consent by specifically discussing and documenting donor-recipient CMV risks before transplantation.

    Verbatim wording from the response

    “It was acknowledged that the consent process regarding the communication of donor risks, particularly CMV status, needed to be more robust and comprehensive so that all recipients are fully informed before transplantation.”

    Source location

    2019-0271-Response-by-Manchester-University-NHS-Trust
    Page 1 · response
    Published 18 October 2019

    Open published response
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Data last updated 7 September 2026