16 Jun 2017 Katherine Anne Derbyshire · Prevention of Future Deaths report Manchester West
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Concerns raised 5
Failure to triage clinical needs to effect timely transfer View source Inadequate communication between hospitals about dialysis transfer and bed availability View source Delays in considering alternative temporary dialysis View source
Failure to transfer patients requiring ongoing dialysis treatment and care View source Failure of dialysis treatment and care plans to provide for patient deterioration View source See 2 more concerns
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AI-generated summary
Katherine Anne Derbyshire · 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
Katherine Anne Derbyshire, who had end stage chronic kidney disease, was admitted on 12 November 2016 after compromised dialysis function and a presumed blockage and infection of her peritoneal catheter. She deteriorated while awaiting transfer for ongoing dialysis, became unfit for transfer, and died on 21 November 2016 after palliative end-of-life medication was prescribed. The concerns included the failure to transfer her, delays in considering temporary dialysis, and inadequate communication and contingency planning between the two hospitals.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to triage clinical needs to effect timely transfer
Wider context from the report “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:-
a. No transfer to Salford Royal Infirmary, in fact, took place;
b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary;
c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case;
2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that:
a. This possible alternative was not considered earlier;
b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care ;
c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016.
d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient;
3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and care.
” Source location Katherine Anne Derbyshire · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate communication between hospitals about dialysis transfer and bed availability
Wider context from the report “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:-
a. No transfer to Salford Royal Infirmary, in fact, took place;
b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary;
c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case;
2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that:
a. This possible alternative was not considered earlier;
b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care;
c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016.
d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient ;
3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and care.
” Source location Katherine Anne Derbyshire · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in considering alternative temporary dialysis
Wider context from the report “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:-
a. No transfer to Salford Royal Infirmary, in fact, took place;
b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary;
c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case;
2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that:
a. This possible alternative was not considered earlier ;
b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care;
c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016.
d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient;
3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and care.
” Source location Katherine Anne Derbyshire · Prevention of Future Deaths report
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 transfer patients requiring ongoing dialysis treatment and care
Wider context from the report “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:-
a. No transfer to Salford Royal Infirmary, in fact, took place ;
b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary;
c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case;
2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that:
a. This possible alternative was not considered earlier;
b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care;
c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016.
d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient;
3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and care.
” Source location Katherine Anne Derbyshire · Prevention of Future Deaths report
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 of dialysis treatment and care plans to provide for patient deterioration
Wider context from the report “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:-
a. No transfer to Salford Royal Infirmary, in fact, took place;
b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary;
c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case;
2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that:
a. This possible alternative was not considered earlier;
b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care;
c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016.
d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient;
3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and care.
” Source location Katherine Anne Derbyshire · Prevention of Future Deaths report
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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 Develop and implement an inter-hospital electronic referral system with standardised guidance, safety prompts, responsibility assignment and documented telephone referrals.
Verbatim wording from the response “Electronic Referral Pathways
SRFT are developing an inter-hospital online referral system which aims to standardise advice and guidance as well as providing prompts for specific information. The system will automate the following:” Source location 2017-0199-Response-by-Salford-Royal-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a joint clinical working group to create a safe patient-transfer pathway and consider measures to avoid transfer delays.
Verbatim wording from the response “A working group is also to be set up to include clinicians from both Trusts, led by ████████ a Consultant in Acute Medicine at WWL, to prepare a pathway to facilitate the safe transfer of patients as soon as a bed becomes available and to ensure that there continues to be effective communication with SRFT.” Source location 2017-0199-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
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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 an electronic on-call referral system enabling instant referral, timely renal advice and documented communications.
Verbatim wording from the response “The two Trusts are also working together to implement a system which will enable the instant and electronic referral of patients to the on-call Renal team (based at SRFT). The system will allow timely advice to be provided and will ensure that all conversations between the referring Trust and the Renal Centre are clearly documented.” Source location 2017-0199-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
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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 a consultant-led renal in-reach service at WWL for inpatient advice and management, supported by recruited consultants.
Verbatim wording from the response “In Reach
Salford Royal NHS Foundation Trust (SRFT) is the lead provider in the north sector of Greater Manchester, covering the following six CCG areas: Salford, Bolton, Wigan, Wrightington & Leigh (WWL), Bury, Rochdale, and Oldham.
An ‘in reach’ model of care is in place in Pennine Acute (Oldham & Bury) and Royal Bolton Trust. In reach involves a Specialist Consultant attending the local hospital to provide renal advice or management at the local hospital for inpatients. WWL and SRFT have not had such an arrangement in place. However in recent weeks SRFT and WWL have worked collaboratively to address this gap and discussions are in their final stages. Consultants have been recruited and subject to the human resource checks it is expected they will be available to commence an ‘in reach’ service at WWL from 7th August 2017.” Source location 2017-0199-Response-by-Salford-Royal-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Daily advice was sought, treatment recommendations were documented and followed, so communication between the hospitals did not raise a fundamental concern.
Verbatim wording from the response “It is very clear from Mrs Derbyshire’s records that there was a high level of daily communication with the renal team at SRFT to discuss Mrs Derbyshire’s condition and treatment and to enquire if a bed was available for transfer. The Trust therefore, respectfully disputes the suggestion that the quality of communication with SRFT between 14th and 20th November 2016 raises a fundamental issue of concern. The advice of the renal team at SRFT was requested daily, the recommended treatment plan was clearly documented in Mrs Derbyshire’s notes and was followed accordingly.” Source location 2017-0199-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
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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 patient's deterioration prompted renewed renal discussion and ICU review; haemofiltration had previously been considered but deemed unsuitable.
Verbatim wording from the response “In response to your concern regarding the lack of evidence of a plan for the action to be taken in the event of the deterioration, please be reassured that when Mrs Derbyshire’s condition deteriorated on 20th November 2016, her treatment was again discussed with the renal team at SRFT and only at this stage was the advice given to discuss haemofiltration with ICU. The Intensive Care team promptly reviewed Mrs Derbyshire and as noted above, made a difficult risk-benefit assessment to decide on the appropriate treatment for Mrs Derbyshire, following consultation with her family and all the clinicians involved in her care. Prior to this deterioration, Mrs Derbyshire’s condition did not require urgent dialysis and whilst consideration was given to haemofiltration, as noted in Mrs Derbyshire’s notes on 17 November 2016, it was concluded that Mrs Derbyshire was not suitable for this treatment.” Source location 2017-0199-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further renal replacement therapy was not considered in the patient's best interests because its benefits were limited and its clinical risks significant.
Verbatim wording from the response “Mrs Derbyshire was reviewed by ████████ (ST7 Intensive Care) at 12.30 hours on 20 November 2016. ████████ noted that haemofiltration would be a temporary measure and would be unlikely to have helped Mrs Derbyshire to return to her previous state. Mrs Derbyshire’s condition and treatment was discussed with ████████ (Consultant Intensivist) and ████████ (Consultant in Renal Medicine at SRFT) and on the basis of a risk-benefit analysis the conscious decision was taken that further renal therapy would not be in Mrs Derbyshire’s best interests. The decision included consideration of Mrs Derbyshire’s very poor functional baseline leading up to her hospitalisation, her poor quality of life on such treatment and the fact that she was close to the end of her life.” Source location 2017-0199-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
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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 Transfer to another Trust cannot be facilitated until that Trust has an available bed; interim treatment is provided meanwhile.
Verbatim wording from the response “I hope the above response is a testament to how seriously the Trust considers the concerns raised by Mrs Derbyshire’s death. I can reassure you that WWL will continue to work with SRFT and other Trusts to try to avoid delays in transferring patients. Unfortunately however, if a patient requires transfer to another Trust for specific treatment, WWL cannot facilitate this transfer until a bed becomes available. The Trust then offers the best treatment to optimise care in the interim.” Source location 2017-0199-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
Open published response
8 May 2017 Andrew Jonathan WILSON · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 5
Lack of arrangements to provide peritoneal dialysis at hospitals other than the renal unit View source Unavailability of equipment for peritoneal dialysis View source Failure of treating clinicians to know when peritoneal dialysis cannot be arranged at the hospital View source
Unavailability of trained staff to provide peritoneal dialysis View source Lack of arrangements to transport peritoneal dialysis equipment from a patient's home to hospital View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Andrew Jonathan 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
Andrew Jonathan Wilson had end-stage renal failure managed with home peritoneal dialysis and was admitted to Maidstone Hospital with sepsis on 20 July 2015. Peritoneal dialysis was unavailable at Maidstone Hospital and its satellite renal unit for three nights before he was transferred to the Kent and Canterbury Hospital, where dialysis was recommenced. He later deteriorated and died of natural causes; concerns were raised about the lack of arrangements, trained staff, equipment, and clinician awareness needed to provide peritoneal dialysis outside the Canterbury renal unit.
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× 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 arrangements to provide peritoneal dialysis at hospitals other than the renal unit
Wider context from the report “(1) Although it was established on the balance of probability (after hearing the clinicians and an independent expert Consultant Nephrologist) that the absence of peritoneal dialysis on THIS occasion did not contribute to the death, the absence of any arrangements to provide peritoneal dialysis at hospitals other than the renal unit at Canterbury raised a concern.
(2) There was an apparent absence of knowledge on the part of the treating clinicians at Maidstone Hospital that peritoneal dialysis could not be arranged either during the day or over-night at that hospital as there were no trained staff available nor was the equipment available. There were no arrangements in place to transport the equipment from the home of a patient to the hospital.
” Source location Andrew Jonathan WILSON · Prevention of Future Deaths report
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 Unavailability of equipment for peritoneal dialysis
Wider context from the report “(1) Although it was established on the balance of probability (after hearing the clinicians and an independent expert Consultant Nephrologist) that the absence of peritoneal dialysis on THIS occasion did not contribute to the death, the absence of any arrangements to provide peritoneal dialysis at hospitals other than the renal unit at Canterbury raised a concern.
(2) There was an apparent absence of knowledge on the part of the treating clinicians at Maidstone Hospital that peritoneal dialysis could not be arranged either during the day or over-night at that hospital as there were no trained staff available nor was the equipment available . There were no arrangements in place to transport the equipment from the home of a patient to the hospital.
” Source location Andrew Jonathan WILSON · Prevention of Future Deaths report
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 of treating clinicians to know when peritoneal dialysis cannot be arranged at the hospital
Wider context from the report “(1) Although it was established on the balance of probability (after hearing the clinicians and an independent expert Consultant Nephrologist) that the absence of peritoneal dialysis on THIS occasion did not contribute to the death, the absence of any arrangements to provide peritoneal dialysis at hospitals other than the renal unit at Canterbury raised a concern.
(2) There was an apparent absence of knowledge on the part of the treating clinicians at Maidstone Hospital that peritoneal dialysis could not be arranged either during the day or over-night at that hospital as there were no trained staff available nor was the equipment available. There were no arrangements in place to transport the equipment from the home of a patient to the hospital.
” Source location Andrew Jonathan WILSON · Prevention of Future Deaths report
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 Unavailability of trained staff to provide peritoneal dialysis
Wider context from the report “(1) Although it was established on the balance of probability (after hearing the clinicians and an independent expert Consultant Nephrologist) that the absence of peritoneal dialysis on THIS occasion did not contribute to the death, the absence of any arrangements to provide peritoneal dialysis at hospitals other than the renal unit at Canterbury raised a concern.
(2) There was an apparent absence of knowledge on the part of the treating clinicians at Maidstone Hospital that peritoneal dialysis could not be arranged either during the day or over-night at that hospital as there were no trained staff available nor was the equipment available. There were no arrangements in place to transport the equipment from the home of a patient to the hospital.
” Source location Andrew Jonathan WILSON · Prevention of Future Deaths report
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 Lack of arrangements to transport peritoneal dialysis equipment from a patient's home to hospital
Wider context from the report “(1) Although it was established on the balance of probability (after hearing the clinicians and an independent expert Consultant Nephrologist) that the absence of peritoneal dialysis on THIS occasion did not contribute to the death, the absence of any arrangements to provide peritoneal dialysis at hospitals other than the renal unit at Canterbury raised a concern.
(2) There was an apparent absence of knowledge on the part of the treating clinicians at Maidstone Hospital that peritoneal dialysis could not be arranged either during the day or over-night at that hospital as there were no trained staff available nor was the equipment available. There were no arrangements in place to transport the equipment from the home of a patient to the hospital .
” Source location Andrew Jonathan WILSON · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to undertake contingency planning between treating clinicians and specialist critical care team View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Margaret Erskin Hare Wakefield · 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
Margaret Wakefield, who had severe heart and renal disease, deteriorated after a high-risk cardiac procedure and died following a cardiac arrest on 5 February 2016. The report identified concerns about the lack of timely haemofiltration and the need for improved access and contingency planning for critically ill patients requiring it.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to undertake contingency planning between treating clinicians and specialist critical care team
Wider context from the report “Margaret Wakefield suffered from unstable mental health which on occasions meant she had lack of insight into her medical needs. It was recognised by both the Cardiac Surgeon and Renal Consultant that she was very unwell, the procedure was high risk and that she would require dialysis and that Critical Care haemofiltration may be required. Mrs Wakefield deteriorated quickly and when a request for haemofiltration (which was necessary and potentially lifesaving) was made it was not available in a timely way. The lack of haemofiltration resulted in further deterioration and death occurred before the facility could be made available.
The Consultant Surgeon and Renal Consultant both raised concerns as to the lack of haemofiltration for a patient with chronic renal disease following high risk heart procedure in a timely way, and the need for improved access to timely haemofiltration and contingency planning between the treating clinicians and Specialist critical care team .
” Source location Margaret Erskin Hare Wakefield · Prevention of Future Deaths report
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Includes failures of arrangements dedicated to delivering ongoing or emergency dialysis treatment, including treatment availability at hospitals, transfer between dialysis services, equipment provision and contingency planning when treatment cannot be provided as intended.
