Recurring concern

Failure to reliably implement consultant clinical instructions

First to latest report 8 Apr 2014 — 12 Nov 2020

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
5

What this concern includes

Includes failures of the dedicated process for receiving, communicating, implementing or escalating consultant clinical instructions for patient care, including medication provision before surgery and ordered clinical interventions such as NG-tube insertion.

What is not included
  • Excludes failures to follow general policies, protocols or guidelines where no consultant clinical instruction is involved.
  • Excludes failures concerning consultant availability, review or attendance where the instruction-implementation process is not deficient.
  • Excludes failures to implement patient instructions, multidisciplinary recommendations or instructions from non-consultant staff unless the assertion explicitly concerns a consultant clinical instruction.
  • Excludes generic communication, staffing or documentation deficiencies unless they directly cause a consultant clinical instruction to be omitted, delayed or left without appropriate escalation.

Reports and published responses 4 reports

See individual reports that have raised this concern, and the actions taken in response

  1. East London

    AI-generated summary

    Amarbai Bhudia · 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

    Amarbai Bhudia was admitted to hospital with abdominal pain and vomiting and was managed for a small intestine obstruction using a naso-gastric tube. The tube was not aspirated, and she collapsed and suffered a cardiac arrest caused by aspiration of gastro-intestinal contents; concerns included unclear instructions, lack of nursing guidance and training, and inadequate escalation of concerns about the tube.

    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 clearly record instructions on NG tube management

    Wider context from the report

    “1. Instructions on the management of the NG tube were provided on a ward round by a consultant, the instructions were not clearly noted by the House Officer accompanying the consultant. 2. Nursing staff had no clinical instruction as to how to manage the NG tube. 3. Nursing staff dealing with the patient were agency staff without training or experience of NG tube management. 4. Concerns regarding the NG tube function were not properly escalated to clinical staff. ”

    Source location

    Amarbai Bhudia · 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 a structured surgical ward-round communication process following an audit of clinical instruction quality.

    Verbatim wording from the response

    “In response to concerns in the department of surgery regarding the quality and content of communications about clinical instructions, an audit was designed and implemented by the junior surgery team. This identified that there was a need for a structured ward round template, and showed that implementation of a structured ward round improved communication on the ward. This audit was accepted for presentation at The Royal College of Surgeons of Edinburgh, though the conference did not take place due to the pandemic.”

    Source location

    2020-0232-Response-from-Barts-Health-NHS-Trust-Redacted.pdf
    Page 1 · response
    Published 23 December 2020

    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

    Record medical plans in a nursing diary to support effective communication.

    Verbatim wording from the response

    “Furthermore, a new assurance template has been introduced to spot-check the presence of the nursing team on ward rounds. The medical plans are entered into a diary by the nurses to ensure the plans are communicated effectively. The Nurse in Charge checklist has now been introduced including clear guidance regarding the roles and responsibilities of the person coordinating the ward area.”

    Source location

    2020-0232-Response-from-Barts-Health-NHS-Trust-Redacted.pdf
    Page 2 · response
    Published 23 December 2020

    Open published response

  2. Herefordshire

    AI-generated summary

    Mary Bertha Johnson · 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

    Mary Bertha Johnson died at County Hospital, Hereford, on 25 July 2018 after falling on 20 July 2018 and sustaining a periprosthetic fracture of the femur. Concerns included poor communication about feeding and medication before surgery, and the suggestion that porter availability affected the hospital theatres’ ability to carry out operations.

    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 adhere to Consultant instructions on medication provision prior to operation

    Wider context from the report

    “(1) A lack of communication between staff highlighted issues concerning: (a) the feeding of patients prior to operation (b) adherence to the Consultant’s instructions regarding the provision of medication prior to operation ”

    Source location

    Mary Bertha Johnson · 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

    Relaunch and clarify thromboprophylaxis guidance for relevant staff, including when prophylaxis should be withheld before surgery.

    Verbatim wording from the response

    “Although not actually the root cause for this patient’s death, we have also taken the opportunity to relaunch and clarify to all pertinent staff, the use of thromboprophylaxis prior to surgery, particularly the time period before which it should be withheld. In addition to this, and this is an ongoing piece of work, all speciality specific thromboprophylaxis guidelines are being reviewed and I would be happy to update you on the progress of this at a later date.”

    Source location

    2019-0458-Response-by-Wye-Valley-NHS-Trust
    Page 2 · response
    Published 1 February 2019

    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 all specialty-specific thromboprophylaxis guidelines.

    Verbatim wording from the response

    “Although not actually the root cause for this patient’s death, we have also taken the opportunity to relaunch and clarify to all pertinent staff, the use of thromboprophylaxis prior to surgery, particularly the time period before which it should be withheld. In addition to this, and this is an ongoing piece of work, all speciality specific thromboprophylaxis guidelines are being reviewed and I would be happy to update you on the progress of this at a later date.”

    Source location

    2019-0458-Response-by-Wye-Valley-NHS-Trust
    Page 2 · response
    Published 1 February 2019

    Open published response

  3. Worcestershire

    AI-generated summary

    Bryan Arnold CATANACH · 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

    Bryan Arnold Catanach sustained a fractured odontoid peg and cervical injury after a fall, and died in hospital on 8 February 2015 after his condition deteriorated. The report identified concerns about communication and delays in transfer and senior review, inpatient falls prevention, and the availability and use of appropriate traction equipment.

    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 carry out Consultants' instructions and communicate when they cannot be carried out

    Wider context from the report

    “(2) Additional concerns over communication were identified with clear instructions from Consultants not being carried out. In particular, an instruction to have the deceased transferred to the Royal Orthopaedic Hospital before 08:00 hours on 5th February 2015 was cancelled (on the wrong basis that no spare bed was available) and the cancellation of the transfer was not communicated back to the consultant. Additionally, an instruction by the consultant to a junior doctor directing his Registrar to review Mr Catanach was only partly acted upon. This led to a delay in the senior review of Mr Catanach which, when it took place 9 hours after admission, recognised a deterioration in his condition. It is a matter for the Trust to reflect on how best to ensure that Consultants' instructions are fully acted upon and where, for whatever reason, that proves impossible, the situation is communicated back to the Consultant concerned. ”

    Source location

    Bryan Arnold CATANACH · 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

    Refresh and simplify proforma-based documentation for nursing and medical multidisciplinary teams.

    Verbatim wording from the response

    “Additional concerns over communications Following apparent communication and messaging issues identified in this case, Mr Newton-Ede has led a piece of work to refresh and simplify proforma based documentation. Both nursing and medical members of the multi-disciplinary team have been involved in delivering this change. There is a clearly held view from clinical colleagues that these developments have already been seen to be positively impacting on improved communication flow and necessary escalation.”

    Source location

    Bryan-Catanach-Response
    Page 2 · response
    Published 1 December 2015

    Open published response

  4. Manchester South

    AI-generated summary

    Frederick William Hall · 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 days after a right hemicolectomy, Frederick William Hall was taken for a CT scan without the nasogastric tube that had been ordered to decompress his distended abdomen. He vomited and aspirated gastric contents, developing aspiration pneumonia. The concerns included inadequate training in passing nasogastric tubes, failures to follow clinical instructions, poor monitoring and communication, inadequate record-keeping, and insufficient staffing for the demands on the wards.

    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 respond promptly to Consultant instructions

    Wider context from the report

    “4. There was a lack of response (or timely response) to the instructions given by the Consultant. On the night of the 30th September the Consultant ordered an NG tube passed before the scan was carried out. This did not happen. On the 29th September the Consultant had also ordered an NG tube be passed if the patient "starts vomiting or not relieved"; this was not acted on, nor did the nursing staff seek to gain the advice/help of the Consultant or the RMO. ”

    Source location

    Frederick William Hall · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026