25 Sep 2025 Pamela Ann HONEYBONE · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 3
Failure to positively identify patients during treatment encounters View source Continuing risk from patient misidentification View source Failure to positively identify patients before radiology transfer and CT scanning View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
York and Scarborough Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
York and Scarborough Teaching Hospitals NHS Foundation Trust
Review the patient identification policy and strengthen adherence using learning from the case.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Communicate Trust-wide reminders to staff about the importance of positive patient identification.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Audit compliance with the patient identification policy regularly.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Complete development and governance review of a standardised checklist for all radiological transfers.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Obtain approval, publish and deploy the standardised radiology transfer checklist for use.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Empower radiographers to decline radiological investigations when the transfer checklist is incomplete.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Monitor checklist compliance through Radiology clinical governance meetings and escalate issues to the Care Group Board.
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AI-generated summary
Pamela Ann HONEYBONE · 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
Pamela Ann Honeybone was admitted to Scarborough General Hospital after a fall and died there on 19 October 2024 after being moved to end-of-life care. Another patient with the same first name underwent her required CT scan in error, delaying diagnosis of an abdominal mass suggestive of lymphoma; the inquest concluded that it was not possible to determine whether this contributed to her death. The report identified continuing patient-safety risks from patient misidentification, delayed responses to recognised errors, incomplete investigation, and gaps in patient-identification processes.
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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 positively identify patients during treatment encounters
Wider context from the report “5. An Action Plan was drawn up as a result of the Trust investigation, but for various reasons no audit of compliance with patient identification processes commenced until early August 2025, some ten months after Mrs Honeybone's death. The results of the audit thus far were made available to me at inquest and indicate that 1 in 5 audited treatment encounters between staff of all grades and specialisms still occur without the patient being positively identified .
” Source location Pamela Ann HONEYBONE · 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 Continuing risk from patient misidentification
Wider context from the report “7. I consider the above represent a continuing risk to others from misidentification and delayed responses to identified errors, with clear implications for patient safety.
” Source location Pamela Ann HONEYBONE · 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 Failure to positively identify patients before radiology transfer and CT scanning
Wider context from the report “1. It was accepted in evidence that neither the doctor who escorted the wrong patient from the Emergency Department to radiology, nor the radiographer who undertook the CT scan on her, checked the identity of the patient in question . No transfer checklist was completed , and the patient was not asked to complete and/or sign the CT scanning questionnaire herself . No member of staff inquired as to the outcome of this patient's CT scan prior to her discharge a few hours later.
” Source location Pamela Ann HONEYBONE · 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 Review the patient identification policy and strengthen adherence using learning from the case.
Verbatim wording from the response “The Trust has an Identification of Patients policy in place. This has recently been reviewed and findings from this case have been used to strengthen adherence to the identification process.” Source location Response from York and Scarborough 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 Communicate Trust-wide reminders to staff about the importance of positive patient identification.
Verbatim wording from the response “In addition, it is reassuring to note, in relation to the audit results presented at inquest by Matron ████████, there has been a significant improvement in positive patient identification in more recent audits following Trust wide communication reminding staff of the importance of positive patient identification. This policy is also subject to regular audit to confirm compliance.” Source location Response from York and Scarborough 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 Audit compliance with the patient identification policy regularly.
Verbatim wording from the response “In addition, it is reassuring to note, in relation to the audit results presented at inquest by Matron ████████, there has been a significant improvement in positive patient identification in more recent audits following Trust wide communication reminding staff of the importance of positive patient identification. This policy is also subject to regular audit to confirm compliance.” Source location Response from York and Scarborough 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 Complete development and governance review of a standardised checklist for all radiological transfers.
Verbatim wording from the response “The action in the Patient Safety Incident Investigation (PSII) report to standardise the radiology transfer checklist is almost complete. It was acknowledged that the CT transfer checklist in place at the time of Mrs Honeybone’s admission was not robust and not in place across the Trust. It was agreed that a transfer checklist was needed for all radiological investigations, not just CT scans. The checklist has been drafted and reviewed in consultation with the wider Radiology and nursing team and a final draft is awaiting sign off at the Radiology Governance Board. The checklist is due to be published and deployed for use at the end of November 2025.” Source location Response from York and Scarborough 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 Obtain approval, publish and deploy the standardised radiology transfer checklist for use.
Verbatim wording from the response “The action in the Patient Safety Incident Investigation (PSII) report to standardise the radiology transfer checklist is almost complete. It was acknowledged that the CT transfer checklist in place at the time of Mrs Honeybone’s admission was not robust and not in place across the Trust. It was agreed that a transfer checklist was needed for all radiological investigations, not just CT scans. The checklist has been drafted and reviewed in consultation with the wider Radiology and nursing team and a final draft is awaiting sign off at the Radiology Governance Board. The checklist is due to be published and deployed for use at the end of November 2025.” Source location Response from York and Scarborough 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 Empower radiographers to decline radiological investigations when the transfer checklist is incomplete.
Verbatim wording from the response “Radiographers will be empowered to decline investigations if the checklist is not complete. This will be monitored at the Radiology clinical governance meetings and escalated to the Cancer Specialist & Support Services Care Group Board.” Source location Response from York and Scarborough 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 Monitor checklist compliance through Radiology clinical governance meetings and escalate issues to the Care Group Board.
Verbatim wording from the response “Radiographers will be empowered to decline investigations if the checklist is not complete. This will be monitored at the Radiology clinical governance meetings and escalated to the Cancer Specialist & Support Services Care Group Board.” Source location Response from York and Scarborough NHS Trust
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16 Feb 2024 Mr Roberto Bottello · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Insufficient training of SPA call handlers in patient identification and information seeking View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mr Roberto Bottello · 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
Roberto Bottello, who had been experiencing depression, anxiety, panic attacks and later an acute psychotic episode, was detained under section 136 of the Mental Health Act after police found him acutely disturbed. While in a hospital cubicle, he broke the window and fell 25 feet, suffering multiple injuries including a divided axillary vein and artery; his death was announced at 07:27 on 16 September 2020. Substantive concerns included the unsuitability and inadequate safety of the cubicle, communication and information-management failures, insufficient mental-health nursing provision, confusion over his identity, limited access to section 136 suites, and wider concerns about training and psychiatric-care resources.
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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 Insufficient training of SPA call handlers in patient identification and information seeking
Wider context from the report “3. That SPA call handlers were not sufficiently trained in how to identify patients by using computer searches and by not seeking information appropriately for example by using the international phonetic alphabet and using the word for the month in a person’s date of birth .
” Source location Mr Roberto Bottello · 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 Provide SPA call handlers with induction guidance, phonetic-alphabet prompts and a minimum-question checklist for identifying patients and callers.
Verbatim wording from the response “• SPA has developed an induction pack, which specifically includes guidance on various ways of searching or identifying patient via system one/SPINE. All SPA staff now use phonetic alphabet when clarifying patients or callers’ details. On each desk within SPA there is a list of the phonetic alphabet, to support and prompt staff to ensure they have the correct spelling. SPA also has a checklist for call handlers, which prompts them to ask certain questions as a minimum, so information is not missed during calls.” Source location Response from Central and NW London NHS
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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 Provide recruit officers with phonetic-alphabet training through handouts, simulated radio transmissions and Street Duties role-play practice.
Verbatim wording from the response “All MPS officers complete a mandatory training package developed by the College of Policing (the professional body setting training standards for forces across England and Wales) called “Airwaves Radios”. This is hosted on College Learn (the national online training platform for police officers and staff). Within the first three weeks of initial learning, recruit police officers are provided with a handout” Source location Response from Metropolitan Police Service
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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 Amend the airwave-etiquette handout to emphasise using the phonetic alphabet for name checks.
Verbatim wording from the response “¹ This document is being amended to emphasise the requirement to use the phonetic alphabet to conduct a name check (Example 3). This was presented as a minor change for immediate action, and implementation will be confirmed at the next Curriculum Design Authority Group next month.” Source location Response from Metropolitan Police Service
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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 Existing MPS provision is considered sufficient to meet the phonetic-alphabet learning need for new recruits.
Verbatim wording from the response “MPS Learning and Development undertake a learning needs analysis following any recommendations (for example, from external reports and inquiries) to understand if there is an organisational learning need and who the learner audience is. Where the learner audience is exclusively new recruits, the Centre for Initial Recruit Learning will address the learning need through an established Curriculum Design Authority. This will include an assessment of whether the learning need is being met through our current provision, or whether new or updated content is required. This will be assessed in the context of the National Police Curriculum set by the College of Policing.” Source location Response from Metropolitan Police Service
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20 Jan 2022 Neil Kenneth PARKES · Prevention of Future Deaths report Warwickshire
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Concerns raised 1
Failure to identify unconscious patients View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Warwickshire Police
Issue organisation-wide learning requiring hospital enquiries to identify unknown patients, linked incidents to be researched, and fingerprints to be considered where medically relevant.
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AI-generated summary
Neil Kenneth PARKES · 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
Neil Kenneth Parkes was found unconscious after an apparent unwitnessed fall in a stairwell on 29 April 2020 and later died in hospital on 14 May 2020. His identity remained unknown throughout his hospital admission despite reports from hospital staff and his parents, and the failure to identify him meant the hospital could not access his previous medical history, which may have assisted his treatment.
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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 identify unconscious patients
Wider context from the report “Throughout the time that Mr Parkes lay unconscious in UHCW his identity was unknown . He had been reported as a missing person by his parents to another police force during the time he was in hospital. Additionally, on 2 separate occasions, UHCW staff directly contacted Warwickshire police to seek assistance to identify him. No clear explanation has been provided to explain why Warwickshire failed to act on those requests. The effects of the failure to identify Mr Parkes meant the hospital had no access to his previous medical history which my have been of assistance in his treatment.
” Source location Neil Kenneth PARKES · 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 Issue organisation-wide learning requiring hospital enquiries to identify unknown patients, linked incidents to be researched, and fingerprints to be considered where medically relevant.
Verbatim wording from the response “• An entry made available to all officers and staff through the Vulnerability and Safeguarding Newsletter on 1st December 2021 setting out lessons learnt from this Inquest. They were as follows:
◦ The necessity for officers conducting hospital enquiries to ask specifically for details of any “unknown” or “unidentified” patients within their care.
◦ The necessity to consider researching other local incidents which may be linked to missing person enquiries.
◦ The necessity to take fingerprints (using the Mental Capacity Act 2005 provisions) where establishing identity may assist with treatment of a medical need.” Source location 2022-0019-Response-from-Warwickshire-Police_Published
Open published response
Concerns raised 1
Absence of an effective system to identify patients under the care of departing staff View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
John Atkinson · 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
John Atkinson received psychiatric services after contacting the Mental Health Team in crisis in July 2014 and died by suicide by hanging. The report identified concerns about outdated risk assessments, failures to recognise changing presentation and risk, inadequate arrangements when staff left, poor communication, and difficulty accessing Home Treatment Team services.
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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 Absence of an effective system to identify patients under the care of departing staff
Wider context from the report “(3) Absence of an effective and robust system to identify and then manage patients under the care of departing staff (for example care co-ordinator).
” Source location John Atkinson · 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 assess an improved patient-allocation system for staff absences, including a flow chart, interim oversight, risk assessment and RAG prioritisation.
Verbatim wording from the response “The ICT team is presently reviewing an improved system of allocating patients when staff members are unavailable due to sickness, planned leave or resignation. The service manager is working with the team to devise a simple flow chart which clearly identifies the system of allocating patients. As part of this work there is a review of leadership roles within the ICT team, again part of the improvement plan.
Presently the team manager is responsible for oversight of patients when the care coordinator is absent and a process of risk assessing each client is in place pending re-allocation. A “RAG” (red, amber and green) rating system is in place which identifies an individual’s risk profile to categorise those patients who need immediate input and those who may require less rigorous oversight.” Source location 2016-0429-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
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28 Jun 2016 David Michael little · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to verify inpatient identity before transfer to radiology View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
David Michael little · 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 Michael Little was admitted to hospital with abdominal pain and a suspected small-bowel mass. His condition worsened, and a scan revealed a blockage caused by ischaemic bowel; delays in scanning, reporting, and insertion of an NG tube meant that surgery was considered when it was deemed too late. The report raised concerns about poor record-keeping, lack of a clear diagnostic and monitoring pathway, failure to recognise the seriousness of bowel obstruction, and poor communication among staff and with the family.
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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 verify inpatient identity before transfer to radiology
Wider context from the report “1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the procedure had been carried out, whether the patient had been returned to the ward. In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient , and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day.
” Source location David Michael little · 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 a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.
Verbatim wording from the response “In addition, there is currently a documented tracking/handover policy in draft (Document 2 attached) which will document any specific requests that are given to the patient via the ward staff to prepare them for their investigation, e.g. nil by mouth or the requirement for a full bladder. It will include a feedback form that the porter will take to the ward when collecting the patient for a member of the nursing staff to sign to confirm the patient’s identification and the test/imaging the patient is scheduled for. On return of the patient to the ward, the sheet will document what investigation has taken place and any special observations required. This form will form a part of the radiology record and be filed in the patient’s notes.” Source location 2016-0237-Response-by-Tameside-Hospital-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 The patient was not taken to radiology by mistake; Radiology records show his scan was scheduled and expected that day.
Verbatim wording from the response “1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the patient had been returned to the ward. In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient, and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day.” Source location 2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Open published response
11 May 2015 Lydia Corah · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Failure to ensure that x-rays are performed for the patient for whom they are intended View source
Linked response
Nottingham University Hospital
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Nottingham University Hospital
Strengthen induction training for new doctors on avoiding multiple open patient pages in the Notis system.
View source
Nottingham University Hospital
Update radiography checking procedures to assess clinical details and manage discrepancies.
View source
Nottingham University Hospital
Operate an established system for reporting and investigating recognised ionising-radiation incidents, including routine root-cause analysis of incorrect imaging referrals.
View source
Nottingham University Hospital
Consider introducing stronger technological barriers, including a patient photograph, to prevent incorrect patient selection in Notis.
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AI-generated summary
Lydia Corah · 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
Lydia Corah died at the Trust hospital from multi-organ failure caused by Group A beta streptococcal sepsis. The report raised concerns about errors that led to her undergoing an X-ray intended for a different patient, causing delay in assessment and treatment and unnecessary radiation, and about the potential adverse effect on the intended patient.
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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 ensure that x-rays are performed for the patient for whom they are intended
Wider context from the report “1. That there was an error, or series of errors, which led to Mrs Corah undergoing an x ray which had been indicated for a different patient , so causing her to experience delay in assessment and treatment and to receive an unnecessary dose of radiation.
2. That the same error, or series of errors, would have adversely affected the patient for whom the x ray request had been properly intended .
” Source location Lydia Corah · 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 Strengthen induction training for new doctors on avoiding multiple open patient pages in the Notis system.
Verbatim wording from the response “f. The NUH Information Technology department has previously highlighted the issue of multiple pages on Notis, and have strengthened the induction training of new doctors in this regard. An assessment of this issue has not provided a technological safeguard as potential barriers to this error were thought to create their own patient safety concerns.” Source location 2015-0181-Response
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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 Update radiography checking procedures to assess clinical details and manage discrepancies.
Verbatim wording from the response “k. The radiography report arrives at recommendations which has generated an Action Plan (appendix 3) managed by the Directorate. These actions are complete and include reflection by the member of staff involved and updating of checking procedures including assessment of the clinical details and how to manage discrepancies.” Source location 2015-0181-Response
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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 Operate an established system for reporting and investigating recognised ionising-radiation incidents, including routine root-cause analysis of incorrect imaging referrals.
Verbatim wording from the response “e. A Root Cause Analysis is routinely employed in all cases of incorrect referrals for medical imaging. The RCA will generate an action plan which is managed by the responsible Directorate. The RCA for this patient is attached (appendix 1). It is difficult to be certain of the cause of the patient identification error. The experienced (Consultant) investigator concludes that the most likely cause to be a mistake whilst using the electronic requesting system (Notis). It is possible to open multiple pages whilst using this system and this has been highlighted as a potential cause for ordering an investigation on the incorrect patient as each open page will belong to a different patient. This type of error is often associated with trainee doctors engaged with caring for more than one patient at busy times.” Source location 2015-0181-Response
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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 Consider introducing stronger technological barriers, including a patient photograph, to prevent incorrect patient selection in Notis.
Verbatim wording from the response “g. The only addition safeguard which has been proposed is the inclusion of a patient photo to the Notis page. This has not been progressed but will be considered in the near future by the NUH Clinical Risk Committee.” Source location 2015-0181-Response
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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 No technological safeguard for incorrect patient selection was implemented because potential barriers were considered capable of creating other patient safety concerns.
Verbatim wording from the response “f. The NUH Information Technology department has previously highlighted the issue of multiple pages on Notis, and have strengthened the induction training of new doctors in this regard. An assessment of this issue has not provided a technological safeguard as potential barriers to this error were thought to create their own patient safety concerns.” Source location 2015-0181-Response
Open published response
7 May 2015 Mrs. Evelyn KENNEDY · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Failure to provide patient identity wristbands View source
This report raised 24 other concerns. They are not shown here because they do not form part of this recurring 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
Mrs. Evelyn KENNEDY · 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
Mrs. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.
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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 provide patient identity wristbands
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” Source location Mrs. Evelyn KENNEDY · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.