Concerns raised 1
Failure to share and act promptly on nursing staff concerns View source
This report raised 11 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
Thomas George Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas George Smith, aged 13, developed symptoms including headache, neck pain and vomiting before being admitted to hospital, where he later became unresponsive and died after suspected meningitis and raised intracranial pressure. The report identified concerns about delays in recognising and treating meningitis and raised intracranial pressure, communication and handover, responding to nursing concerns, monitoring physiological trends, and the transfer of the patient to hospital.
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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 share and act promptly on nursing staff concerns
Wider context from the report “(2) The inquest revealed a somewhat fragmented approach to patient care, with nursing staff concerns not being acted on promptly by doctors . One expert highlighted the importance of a “whole team approach” where information could be freely shared and acted upon by nursing staff professionals . The Coroner suggests that this should be the correct approach. The Coroner noted with concern that at PCH nursing colleagues are not involved in a team debrief. The Coroner considers that they always should be involved.
” Source location Thomas George Smith · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to communicate labour-stage duration effectively to relevant clinical staff View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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Dayani Chauhan-Ahmed · 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
Dayani Chauhan-Ahmed was born in poor condition after a prolonged second stage of labour exceeding 5.5 hours and died after intensive care was withdrawn with parental consent. The substantive concerns included ineffective communication about the length of labour, uncertainty about staff knowledge and adherence to escalation procedures, and insufficient midwifery and medical availability during periods of extreme demand.
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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 communicate labour-stage duration effectively to relevant clinical staff
Wider context from the report “(1) Notwithstanding the presence of all material times of a Consultant on the delivery ward, the length of time of the second stage of this labour did not appear to be communicated effectively to either the Consultant or the midwife co-ordinator , due to other events occurring that night. The “white board” system of communication was ineffective as neither of the above had an opportunity to look at this. The Trust should consider a program for communication on such occasions that is effective and may include slight of the CTG trace, where applicable, by the most senior clinician available.
” Source location Dayani Chauhan-Ahmed · Prevention of Future Deaths report
Open source 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 Require clearer clinical communications, including precise requests for action, through staff reflection and management discussion.
Verbatim wording from the response “1. Our Head of Midwifery has asked the midwife who contacted the consultant to reflect on the importance of clarity when communicating clinical information including being precise in terms of what actions they want to see happen. The importance of clarity particularly in a situation where there is extremely high/intense activity is something that all staff can learn from. In addition our Deputy Clinical Director for Women’s and Children’s Services has discussed with the consultant the importance of ascertaining accurate information if it is not provided. In addition, our Quality and Safety Manager for Women’s and Children’s Services has reminded all clinical staff in the CMG of the importance of pulling the emergency buzzer to summon assistance in an emergency situation.” Source location Response from University Hospital of Leicester 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 A communication pro forma will not be introduced because completing it during emergencies could delay effective action.
Verbatim wording from the response “2. We have carefully considered using a pro-forma to aid effective communication as such pro-formas are used in other circumstances to good effect. However, we have decided not to introduce a pro forma in the situation that occurred here. This is because it is felt that completion of a pro forma is not suitable in emergency situations and would be more likely overall to delay effective action. It is the view of the senior management team of the CMG that it would have been appropriate in this case for the midwife to have used the emergency buzzer. Accordingly, the Head of Midwifery will ensure that the guidelines for the management of the second stage of Labour (Intrapartum Care: Healthy Women and their Babies Guideline) will be reviewed by the end of September 2014, and will strengthen the guidance on the need to use the emergency buzzer in emergency situations.” Source location Response from University Hospital of Leicester NHS Trust
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20 May 2014 Rainer Wickens · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure of communication between junior doctors and radiologists causing delay in CTPA View source
This report raised 6 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
Rainer Wickens · 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
Rainer Wickens fell through the roof of a single-storey rear extension while assisting with its demolition, sustaining a thoracic spine fracture. After surgery, concerns arose about low oxygen saturations and possible pulmonary embolism; he suffered a cardiac arrest and died before testing could be completed. The report identifies concerns about delayed treatment for clot formation, gaps in medical notes, poor handover communication, and delays in obtaining a CTPA scan.
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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 of communication between junior doctors and radiologists causing delay in CTPA
Wider context from the report “Breakdown in communication between junior doctor and radiologist resulting in avoidable delay of CTPA
” Source location Rainer Wickens · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure of two-way communication about prescribing between primary and secondary care View source
This report raised 1 other concern. 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
Denise Sharon Parramore · 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
Denise Sharon Parramore, who had a lengthy history of mental ill health and previous self-harm, died from respiratory depression after taking Tramadol in excess of the prescribed level in combination with other medication. The concerns were that psychiatric services were unaware of the Tramadol prescription and that primary and secondary care should have open two-way communication and access to each other's documentation.
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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 of two-way communication about prescribing between primary and secondary care
Wider context from the report “(1) The Psychiatric Services, and in particular her Consultant Psychiatrist, was not aware, prior to Denise Parramore's death, of her being prescribed Tramadol by her General Practitioner. Concerns would have been raised, and action likely taken, if she had been aware. The Consultant Psychiatrist was not informed either by Mrs Parramore herself, nor the General Practitioner of the prescribing of the Tramadol. My concern is that there should be open, and constant two-way communication between those in primary care and secondary care such as in these circumstances.
” Source location Denise Sharon Parramore · Prevention of Future Deaths report
Open source report
9 May 2014 Linda Yvonne Fisher · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 1
Failure to communicate relevant family medical history effectively to hospital staff involved in care View source
This report raised 2 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
Linda Yvonne Fisher · 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
Linda Yvonne Fisher was admitted to hospital with knee pain and was treated for a suspected deep vein thrombosis. She was found collapsed on 17 October 2013 and died from a pulmonary embolism. Concerns related to medication dosages being based on inaccurately assessed patient weight and relevant family medical history not being obtained and communicated effectively.
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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 communicate relevant family medical history effectively to hospital staff involved in care
Wider context from the report “2. The inquest also heard evidence that other members of the Deceased’s family had suffered from a similar condition. There were no records to suggest that this relevant information had been obtained by medical staff following her admission, and therefore nor had it been communicated effectively to other staff who may in due course have had involvement in her care . I am concerned that if such information is not obtained appropriately from patients and is not communicated effectively to other hospital staff then decisions pertaining to clinical care may be made erroneously and future deaths may result.
” Source location Linda Yvonne Fisher · Prevention of Future Deaths report
Open source report
9 May 2014 Miss Abiola Dosunmu · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to communicate significant proteinuria to the ward View source
This report raised 5 other concerns. 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. 3
The Trust
Refer the case for inclusion in formal Foundation doctor teaching on the significance of marked proteinuria.
View source
The Trust
Share the incident at departmental governance meetings to reinforce recognition and communication of significant proteinuria.
View source
The Trust
Revise the emergency department transfer checklist to include results of tests performed before admission.
View source
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AI-generated summary
Miss Abiola Dosunmu · 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
Abiola Dosunmu developed abnormal blood tests, proteinuria and symptoms that were treated as cellulitis, before rapidly deteriorating and being found dead at home on 24 August 2012. The report identified concerns about failures to communicate the proteinuria and abnormal results, inadequate follow-up and monitoring, and a missed opportunity to diagnose and treat SLE earlier.
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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 communicate significant proteinuria to the ward
Wider context from the report “(1) The 3+ proteinuria discovered in A&E was not communicated to the ward .
” Source location Miss Abiola Dosunmu · 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 Refer the case for inclusion in formal Foundation doctor teaching on the significance of marked proteinuria.
Verbatim wording from the response “a) Training issue: Whilst it is not uncommon to have a trace/+ proteinuria on a urinalysis in a patient with a systemic infection, 3+ proteinuria on a urine dipstick should be recognised as abnormal and needing further investigation. In this case, the result was transcribed to the paper version of the medical admission proforma but not relayed to the inpatient team or noticed by them. The doctors involved in relaying this information no longer work at the Trust, but the Trust will refer the case to be included, as a reminder of the significance of this finding, in the formal teaching of Foundation doctors. The incident has already been shared at departmental governance meetings.” Source location 2014-0209-Response-by-Kings-College-Hospital
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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 Share the incident at departmental governance meetings to reinforce recognition and communication of significant proteinuria.
Verbatim wording from the response “a) Training issue: Whilst it is not uncommon to have a trace/+ proteinuria on a urinalysis in a patient with a systemic infection, 3+ proteinuria on a urine dipstick should be recognised as abnormal and needing further investigation. In this case, the result was transcribed to the paper version of the medical admission proforma but not relayed to the inpatient team or noticed by them. The doctors involved in relaying this information no longer work at the Trust, but the Trust will refer the case to be included, as a reminder of the significance of this finding, in the formal teaching of Foundation doctors. The incident has already been shared at departmental governance meetings.” Source location 2014-0209-Response-by-Kings-College-Hospital
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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 Revise the emergency department transfer checklist to include results of tests performed before admission.
Verbatim wording from the response “b) Electronic records: The Trust supports the initiative from the Emergency Department (ED) to introduce point of care testing (POCT) to allow a faster turnaround of results and also an electronic transfer of results from ED to the ward. POCT has been planned for some time and subject to issues around assurance of the results and the IT interface, this should be in place by December 2014. In the interim, and in response to this incident, ED has revised the transfer checklist for patients being admitted to include results of tests done in ED. The checklist is appended to this report.” Source location 2014-0209-Response-by-Kings-College-Hospital
Open published response
22 Apr 2014 Tanya Rosemary Marion Oladejo · Prevention of Future Deaths report West London
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Concerns raised 1
Failure to communicate medication changes between the GP practice and responsible clinician View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Central and North West London NHS Foundation Trust NHS Hillingdon Clinical Commissioning Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
NHS Hillingdon Clinical Commissioning Group
Review processes for recording medications across different healthcare sectors.
View source
NHS Hillingdon Clinical Commissioning Group
Review processes for communicating medication information between healthcare sectors, including medication changes and treatment follow-up.
View source
NHS Hillingdon Clinical Commissioning Group
Discuss with CNWL and Hillingdon Hospitals pharmacy leads the possibility of developing a standard cross-sector medication letter or form.
View source
NHS Hillingdon Clinical Commissioning Group
Have practice pharmacists review and improve medicines-reconciliation processes in GP practices.
View source
Central and North West London NHS Foundation Trust
Circulate an anonymised Clinical Risk Alert highlighting communication lessons from the case to staff across the organisation.
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Tanya Rosemary Marion Oladejo · 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
Tanya Rosemary Marion Oladejo was found collapsed and unresponsive on her bed after a friend had not heard from her for approximately one week; police confirmed there were no suspicious circumstances. The inquest concluded misadventure, with the medical cause of death recorded as amitriptyline intoxication. The principal concern was inadequate communication between the GP practice and the responsible clinician about medication, including unilateral changes to amitriptyline prescribing that were not communicated to the responsible clinician.
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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 communicate medication changes between the GP practice and responsible clinician
Wider context from the report “(1) The responsible clinician had made adjustments to the prescribed medication regime including allowing the GP to vary the amount of sertraline according to the patient’s presentation.
(2) The GP, in fact, also on occasion titrated the amount of amitriptyline prescribed according to the patient’s presentation.
(3) The responsible clinician was not made aware of the unilateral titration of amitriptyline so, accordingly, was unaware that a drug she had (in discussion with the patient) prescribed to be used as a sleeping draft was, in fact, being prescribed clearly labelled to be taken in the mornings.
(4) In this case, there was a worrying lack of adequate communication between the GP practice and the responsible clinician about medication prescribed to assist in controlling Tanya’s condition
” Source location Tanya Rosemary Marion Oladejo · Prevention of Future Deaths report
Open source 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 processes for recording medications across different healthcare sectors.
Verbatim wording from the response “1. Review the current processes for recording medications in the different sectors by August 2014” Source location 2014-0203-Response-by-Hillingdon-Commissioning-Group
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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 processes for communicating medication information between healthcare sectors, including medication changes and treatment follow-up.
Verbatim wording from the response “On receiving the Initial Management Report a view was sought from the HCCG mental health commissioner, the clinical leads for NWL Mental Health Programme Board, and Hillingdon CCG medicines management lead on 19th May. It was agreed to explore the time frame and process for notification of any change of medication and follow-up sessions of treatment between GPs and CNWL lead clinician. A response from the HCCG Head of Medicines Management was received on 27th May 2014.” Source location 2014-0203-Response-by-Hillingdon-Commissioning-Group
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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 Discuss with CNWL and Hillingdon Hospitals pharmacy leads the possibility of developing a standard cross-sector medication letter or form.
Verbatim wording from the response “3. Discuss with the Pharmacy Leads in CNWL and the Hillingdon Hospitals Trust the possibility of developing one standard letter or form for use across all sectors in July 2014” Source location 2014-0203-Response-by-Hillingdon-Commissioning-Group
Open published 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 Have practice pharmacists review and improve medicines-reconciliation processes in GP practices.
Verbatim wording from the response “4. Ensure our practice pharmacists review and improve medicines reconciliation processes in practices starting in July 2014 and on-going thereafter.” Source location 2014-0203-Response-by-Hillingdon-Commissioning-Group
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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 Circulate an anonymised Clinical Risk Alert highlighting communication lessons from the case to staff across the organisation.
Verbatim wording from the response “I must advise you that in our view the issue of particular concern in this case was one that related to inadequate communication by the GP to our clinician and it is appropriate for the CCG to respond to you on that particular point. We are satisfied that in this case our communication systems were effective. However, as an organisation we are always keen to learn from any incidents that occur and we felt it would be helpful to ensure that staff across our organisation are reminded of the importance of good communication. One of the means we have for disseminating such lessons is a Clinical Risk Alert. We will be circulating an alert in the next few weeks which will include reference to this case (in an anonymised form). I should be happy to forward a copy to you if you would find that of interest.” Source location 2014-0203-Response-by-Central-North-West-London-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 CCG should respond to concerns about inadequate communication by the GP with the Trust clinician.
Verbatim wording from the response “I must advise you that in our view the issue of particular concern in this case was one that related to inadequate communication by the GP to our clinician and it is appropriate for the CCG to respond to you on that particular point. We are satisfied that in this case our communication systems were effective. However, as an organisation we are always keen to learn from any incidents that occur and we felt it would be helpful to ensure that staff across our organisation are reminded of the importance of good communication. One of the means we have for disseminating such lessons is a Clinical Risk Alert. We will be circulating an alert in the next few weeks which will include reference to this case (in an anonymised form). I should be happy to forward a copy to you if you would find that of interest.” Source location 2014-0203-Response-by-Central-North-West-London-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 Trust considered its communication systems effective in this case and did not identify a need to change them.
Verbatim wording from the response “I must advise you that in our view the issue of particular concern in this case was one that related to inadequate communication by the GP to our clinician and it is appropriate for the CCG to respond to you on that particular point. We are satisfied that in this case our communication systems were effective. However, as an organisation we are always keen to learn from any incidents that occur and we felt it would be helpful to ensure that staff across our organisation are reminded of the importance of good communication. One of the means we have for disseminating such lessons is a Clinical Risk Alert. We will be circulating an alert in the next few weeks which will include reference to this case (in an anonymised form). I should be happy to forward a copy to you if you would find that of interest.” Source location 2014-0203-Response-by-Central-North-West-London-NHS-Trust
Open published response
8 Apr 2014 Frederick William Hall · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Deficiencies in communication of clinical information between staff View source
This report raised 7 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
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.
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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 Deficiencies in communication of clinical information between staff
Wider context from the report “5. There were clear and significant deficiencies in communication between and among various staff members ; incomplete information was passed from one RMO to the other on shift hand-over ; the Consultant was not given full information when being spoken to by telephone ; the radiology department were not fully appraised as to the patient's fragile condition . Most notably the RMO did not tell the Consultant that he (the RMO) intended to go to treat another patient on another ward before addressing the passing of the NG tube as instructed.
” Source location Frederick William Hall · Prevention of Future Deaths report
Open source report
2 Apr 2014 Mr John Dodd · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1
Failure to report a documented temperature rise to medical staff View source
This report raised 3 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 John Dodd · 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
Mr John Dodd died from a retroperitoneal haemorrhage at Russells Hall Hospital on 21 April 2013, after being admitted through A&E the previous day. Concerns included that his INR was not checked while he was taking Warfarin, a documented temperature rise was not reported to medical staff before discharge, and there was a delay in his first assessment during his final admission, which was said to have delayed investigation and diagnosis.
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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 report a documented temperature rise to medical staff
Wider context from the report “The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall.
There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff . This was against a background of paracetamol being administered. It was the evidence of ████████ that he would have wanted to know about this and would have wanted the patient reassessed medically prior to the actual discharge from the department. This did not happen, Mr. Dodd having been declared medically fit for discharge prior to the referral to the IMPACT team.
There was a considerable delay on the night of the 20 April between the arrival of Mr. Dodd in A&E and his first assessment by a medically qualified member of staff vis: 20:44 – 00:23. It was the evidence of ████████ that this was inappropriate, and clearly led to a delay in investigation and diagnosis.
” Source location Mr John Dodd · Prevention of Future Deaths report
Open source 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 Use an electronic-system prompt to indicate when abnormal observations need communicating to senior staff.
Verbatim wording from the response “• The Emergency Department will continue to monitor vital signs within nationally recognised guidelines, and a prompt has been incorporated in the clinical electronic information system to indicate the need to communicate abnormal observations to senior staff. Regular board rounds are now in place to ensure that each patient is discussed regularly with senior medical staff.” Source location 2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-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 Hold regular Emergency Department board rounds so each patient is discussed with senior medical staff.
Verbatim wording from the response “• The Emergency Department will continue to monitor vital signs within nationally recognised guidelines, and a prompt has been incorporated in the clinical electronic information system to indicate the need to communicate abnormal observations to senior staff. Regular board rounds are now in place to ensure that each patient is discussed regularly with senior medical staff.” Source location 2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
Open published 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 Reconfigure the electronic clinical information system to create a visible consultant alert when vital signs fall outside normal parameters.
Verbatim wording from the response “• The electronic clinical information system used by the Emergency Department will be reconfigured to create a visible alert to the consultant in charge, when a patient’s vital signs fall outside normal parameters.” Source location 2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
Open published response
21 Mar 2014 MRS KERRY JACOBS · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Lack of a protocol for pharmacist-clinician discussion of queried drug dosages View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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MRS KERRY JACOBS · 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 Kerry Jacobs died on 8 July 2013 from a pulmonary embolism arising from a deep vein thrombosis in her right calf. Concerns included the prescription of a steroid dose outside usual ENT practice and BNF guidelines without adequate documentation or confirmation with the consultant, and the lack of a protocol requiring discussion between pharmacists and clinicians when prescriptions are queried.
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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 Lack of a protocol for pharmacist-clinician discussion of queried drug dosages
Wider context from the report “(2) There was no discussion between the pharmacist and either the prescribing doctor or the patient’s consultant regarding the dosage when the query was raised by the pharmacist. I was informed by the consultant physician who conducted the SUI that, where a pharmacist queries the intended prescription of a drug, it is good practice for the clinician and pharmacist to discuss the matter and consider together the risks and benefits of the prescription. He stated that it “would clearly be of value” to have a protocol requiring such a discussion to take place, where practicable. The Trust has no such protocol.
I consider that, although I did not find that Mrs Jacobs’ death would have been prevented by correction of her prescription, there is a risk that future deaths may occur in similar circumstances and action should be taken to reduce the risk that the prescription of an unintentionally high dose of a drug is not identified and corrected.
” Source location MRS KERRY JACOBS · Prevention of Future Deaths report
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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 Issue a directive requiring clinicians to document the rationale for prescribing outside BNF or usual-practice guidance and record pharmacist prescription-query discussions and outcomes.
Verbatim wording from the response “Response: It is correct that there is no formal Trust policy in place, however, ████████ Chief Medical Officer, has issued a directive to the Chiefs of Service in the Divisions (see attached email dated 4 June 2014) that all staff should record and specify the rationale for the decision to prescribe a medication dosage that is outside guidance within BNF, or usual practice. In addition, when a query is raised by a pharmacist regarding a patient’s prescription, an entry must be made within the patient’s medical records, noting the discussion and outcome. This directive will be disseminated to the clinical staff within each Division, at Multi Disciplinary Team (MDT) meetings each week, and departmental meetings; and will be added to the Trust’s Audit Programme for 2014/2015.” Source location 2014-0133-Response-by-Surrey-Sussex-Healthcare-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 Reiterate the medication-screening procedure requiring direct discussion between prescribing clinicians and screening or dispensing pharmacists, with escalation to another prescriber when necessary.
Verbatim wording from the response “Response: It is correct there is no formal Trust policy in place, however, ████████ Chief Pharmacist, has re-iterated the medication screening procedure to the Trust’s Pharmacy Technicians and Pharmacists. I attach a copy of his email communication dated 7 May 2014 in which he specifically has instructed the Pharmacy Department that “the prescribing clinician and the screening and dispensing pharmacist must have an inter-professional direct discussion about the prescription (not via secretaries), and if the prescribing clinician is not available, then the pharmacy technician or pharmacist must speak to another prescriber clinician who is able to make a decision.”” Source location 2014-0133-Response-by-Surrey-Sussex-Healthcare-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.