Recurring concern

Failure to reliably implement consultant clinical instructions

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First reported 8 Apr 2014•Latest report 12 Nov 2020

Definition

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.

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: 4
Individual concerns: 4
Date range: 2014–2020
Stated actions: 5

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1

Royal London Hospital1

The Alexandra Hospital1

the Royal Orthopaedic Hospital NHS Foundation Trust1

Wye Valley NHS Trust1

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.

12 Nov2020
East London
Concerns raised1
1. Failure to clearly record instructions on NG tube management
This report raised 3 other concerns. 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.
Actions described in response 2
1. Action
  Implement a structured surgical ward-round communication process following an audit of clinical instruction quality.
  Stated by Barts Health NHS TrustStated completed
2. Action
  Record medical plans in a nursing diary to support effective communication.
  Stated by Barts Health NHS TrustStated completed
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
1 Feb2019
Herefordshire
Concerns raised1
1. Failure to adhere to Consultant instructions on medication provision prior to operation
This report raised 2 other concerns. 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.
Actions described in response 2
1. Action
  Relaunch and clarify thromboprophylaxis guidance for relevant staff, including when prophylaxis should be withheld before surgery.
  Stated by Wye Valley NHS TrustStated completed
2. Action
  Review all specialty-specific thromboprophylaxis guidelines.
  Stated by Wye Valley NHS TrustStated in progress
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
1 Dec2015
Worcestershire
Concerns raised1
1. Failure to carry out Consultants' instructions and communicate when they cannot be carried out
This report raised 4 other concerns. 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.
Actions described in response 1
1. Action
  Refresh and simplify proforma-based documentation for nursing and medical multidisciplinary teams.
  Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completed
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
8 Apr2014
Manchester South
Concerns raised1
1. Failure to respond promptly to Consultant instructions
This report raised 7 other concerns. 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.
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to clearly record instructions on NG tube management

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to adhere to Consultant instructions on medication provision prior to operation

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

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

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to respond promptly to Consultant instructions

Actions described in response 2

Actions described in response 2

Actions described in response 1