Concerns raised 2
Failure of the pre-day-surgery assessment system to require questions about patients' haematological family history View source Failure of the pre-day-surgery assessment system to record negative answers about patients' own haematological history View source
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AI-generated summary
Mr Marriott · 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 Marriott underwent haemorrhoidal artery ligation with mucopexy surgery as a day patient and died at home on 15 April 2024; a post-mortem found pulmonary embolism, which the evidence indicated resulted from the surgery. The pre-assessment system did not directly require questions about a patient's haematological family history or record negative answers about the patient's own haematological history.
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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 the pre-day-surgery assessment system to require questions about patients' haematological family history
Wider context from the report “The evidence was that the system which is used for assessment of patients prior to day surgery does not (a) directly require a question to be asked about their haematological family history or (b) record negative answers to the questions related to the patient's own haematological history
” Source location Mr Marriott · 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 of the pre-day-surgery assessment system to record negative answers about patients' own haematological history
Wider context from the report “The evidence was that the system which is used for assessment of patients prior to day surgery does not (a) directly require a question to be asked about their haematological family history or (b) record negative answers to the questions related to the patient's own haematological history
” Source location Mr Marriott · 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 Add family-history prompts, including venous thromboembolism, to the pre-operative assessment form.
Verbatim wording from the response “The patient questionnaire did not have a place for the patient to enter this important family history.
The pre-operative assessment form did not have prompts for the question to be reviewed or asked.
The Trust has now added an extra question on the pre-operative assessment ‘power’ form on the Family History Page. The Trust has also included other potential family history that may need further investigation (for example: cardiac, musculoskeletal).” Source location Response from Surrey and Sussex Healthcare 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 Add the family-history question to the patient questionnaire through a future questionnaire-service update.
Verbatim wording from the response “The Trust has not added this question to the patient questionnaire, but this will be completed with a future update of the questionnaire service itself making the whole process easier for patients. This action will be completed by January 2026.” Source location Response from Surrey and Sussex Healthcare 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 Undertake an after-action review to identify how the gap arose and establish learning and remedial actions.
Verbatim wording from the response “In addition to these urgent clinical and administrative changes, the Trust has also undertaken an After-Action Review to ascertain how this gap was not identified earlier, and to seek recommendations and actions to ensure any learning from the death of a patient is established promptly and action taken.” Source location Response from Surrey and Sussex Healthcare NHS Trust
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29 Oct 2024 Lee Armstrong · Prevention of Future Deaths report Cumbria
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Concerns raised 1
Failure to elicit callers' existing medical conditions 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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AI-generated summary
Lee Armstrong · 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
Lee Armstrong became unwell on 30 January 2024 and, after an initial ambulance-service call, became increasingly unwell before a further call led to an ambulance attending. He suffered an Addisonian Crisis, cardiac arrest and severe brain injury, and died on 2 February 2024. Concerns included the failure of the NHS Pathways system to ask about existing medical conditions, the lack of sharing of information supplied through 111 online with ambulance call handlers, and call handlers' lack of access to relevant medical records.
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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 elicit callers' existing medical conditions
Wider context from the report “(1) The evidence indicates that knowledge that Mr Armstrong suffered from Addison's Disease would have dramatically altered the response to the call. However, the NHS Pathways system does not ask callers to indicate whether they have any existing conditions . Instead, the onus is placed on patients to identify potentially relevant conditions . However, Mr Armstrong had indicated that he was confused. I am concerned that expecting a patient to volunteer crucial information about their condition, especially where that condition may cause confusion, places similar patients at risk .
” Source location Lee Armstrong · Prevention of Future Deaths report
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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 NHS Pathways limits past medical history questions because broader questioning could delay assessment without changing the triage outcome.
Verbatim wording from the response “Past medical history and triage using NHS Pathways
The NHS Pathways system is symptom-based. This means that the presenting clinical picture drives the assessment. Where pre-existing conditions may alter the outcome of symptom assessment, these conditions are enquired about after the initial assessment. Such enquiry is limited to these circumstances because detailed or unnecessary enquiry into past medical history may delay assessment – not only of the caller in question, but globally across the system by affecting average call lengths – without impacting upon the disposition reached.” Source location Response from NHS England
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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 Health advisors are not expected to interpret comprehensive medical records; limited history questions and clinical escalation are considered safer and more effective.
Verbatim wording from the response “Although comprehensive system training is provided, it is not within the scope or remit of the Health Advisor to understand or interpret the full range of medical elements as would be encountered in summary medical records, or from access to information on current medications. It is not safe or effective to expect this staff group to make sense of such information and it could add confusion or delays and cause harm if incorrect conclusions were drawn. It is for these reasons that questions on past medical history or pharmacology are only asked where it is deemed that a clear understanding can be sought and where it might make a difference to the outcome.” Source location Response from NHS England
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20 Oct 2023 Trevor Coy BAILEY · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to elicit relevant family medical history View source
This report raised 3 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. 4
Church Lane Surgery
Update the NHS health-check template to record negative family history of ischaemic heart disease.
View source
Church Lane Surgery
Expand family-history updates to annual chronic-disease checks, medication reviews, ECG appointments and standardised templates.
View source
Church Lane Surgery
Begin updating ischaemic-heart-disease family histories for all patients aged over 25 and inform patients about voluntary updates at registration.
View source
Church Lane Surgery
Train staff to collect and accurately record family-history information in the clinical system.
View source See 1 more action
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AI-generated summary
Trevor Coy BAILEY · 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
Trevor Bailey attended hospital with chest pain on 19 April 2023 and was discharged after negative test results, without referral to the rapid access chest pain clinic. He subsequently died from a fatal myocardial infarction on 7 May 2023; the concern was that his recent smoking history and family history of ischaemic heart disease were not elicited, which may have prevented an appropriate referral.
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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 elicit relevant family medical history
Wider context from the report “1. I heard evidence at inquest that Mr Bailey had a family history of ischaemic heart disease – his brother had had two cardiac stents placed in 2006 and two in 2012.
However, this information was not on Mr Bailey’s medical record, it was not elicited at his 2012 or 2018 health checks and it was not elicited when he consulted his general practitioner, ████████
████████, on 19 or 27 April 2023 .
The recording of this information is unlikely to have changed the outcome for Mr Bailey, but it was a vital part of the medical history and it might easily for another patient.
” Source location Trevor Coy BAILEY · 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 Update the NHS health-check template to record negative family history of ischaemic heart disease.
Verbatim wording from the response “We have taken the following steps to update the family history of coronary heart disease (IHD).” Source location Response from Chuch Lane Surgery
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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 Expand family-history updates to annual chronic-disease checks, medication reviews, ECG appointments and standardised templates.
Verbatim wording from the response “Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates.
We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.” Source location Response from Chuch Lane Surgery
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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 Begin updating ischaemic-heart-disease family histories for all patients aged over 25 and inform patients about voluntary updates at registration.
Verbatim wording from the response “Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates.
We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.” Source location Response from Chuch Lane Surgery
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 Train staff to collect and accurately record family-history information in the clinical system.
Verbatim wording from the response “Currently we assess family history during new patient checks and NHS health checks. We are expanding this practice to include updates on family history at additional points of contact, such as annual chronic disease checks and structured medication reviews, ECG appointments, and have integrated this into our standardised templates.
We have initiated the process of updating family history for all patients aged 25 and above. We have sent the message to all the patients aged >25yrs, to update their family history of IHD. All patients will be informed at registration that they will have to update their family history voluntarily if there are any changes. We have trained the staff to record it in our system. We are going to audit the new entry of family history of IHD every 12 months to assess the progress of our system.” Source location Response from Chuch Lane Surgery
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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 family history was not disclosed during prior consultations, so it was unavailable for consideration in risk assessment and prescribing.
Verbatim wording from the response “It has been discovered that the patient's brother had a history of cardiovascular disease in 2006 and 2012, which was not disclosed during previous encounters in 2012, 2018, or recent visits. As a result, it is now clear that the patient had a family history of cardiovascular disease that was not reported in previous encounters. This information was not taken into account, and the patient was not prescribed any cardio protective medication due to the low cardiovascular risk score as per NICE guidelines.” Source location Response from Chuch Lane Surgery
Open published response
Concerns raised 1
Inadequate questionnaire on the person's medical history 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
Jamie Francis O'Connor · 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
Jamie O’Connor was found deceased in the garden of his home in Leicester on 14 October 2018 after his mother became concerned that he was not responding to phone calls. The report identified concerns about online prescribing, including the lack of central tracking, limited information sharing with GPs, no required face-to-face consultation, limited questionnaires, patients requesting specific drugs, and limited regulation; the inquest concluded that this was a drug-related death and recorded the cause as ████████ toxicity.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate questionnaire on the person's medical history
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” Source location Jamie Francis O'Connor · 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 Establish high-level principles for safe remote consultations and online prescribing with healthcare organisations.
Verbatim wording from the response “We have also worked with other healthcare organisations including regulators, royal colleges and faculties and have jointly-agreed High level principles for good practice in remote consultations and prescribing that set out the good practice of healthcare professionals when prescribing medication online. The ten principles, underpinned by existing expected standards and guidance, include that healthcare professionals are expected to:” Source location 2021-0363-Response-from-GPC_Published
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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 Launch a call for evidence on remote consultations and prescribing to assess whether existing guidance remained appropriate for changing practice and technology.
Verbatim wording from the response “I appreciate that the events giving rise to this inquest date from several years ago. In late 2019 we launched a call for evidence in relation to remote consultations and prescribing. This explored whether our existing guidance, which was last updated in 2013 and which applied at the time of Mr O’Connor’s death, had kept pace with changes in practice and the use of technology.” Source location 2021-0363-Response-from-GMC_Published
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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 Publish updated prescribing guidance covering remote consultation suitability, information sharing, patient dialogue, and safeguards for controlled or potentially addictive medicines.
Verbatim wording from the response “Following this exercise, we published updated guidance for doctors on prescribing in February 2021. This now places a greater emphasis on following the principles of good practice regardless of the medium through which a consultation is taking place, face to face or online.” Source location 2021-0363-Response-from-GMC_Published
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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 Online consultations and prescribing without face-to-face assessment can be safe where appropriate safeguards, history-taking, GP engagement and monitoring exist.
Verbatim wording from the response “Through our regulation of independent online primary medical services, CQC has identified gaps in the regulatory framework for independent online providers. We continue to have concerns about safety gaps, which generally align to those you have identified. We do however recognise there are benefits in the provision of online services, and for consultations and prescribing without the need for a face to face consultation where there are appropriate safeguards in place. These include history taking, engagement with the registered GP, and monitoring, as well as a risk assessing those medicines that are prescribed by a service. Our specific concerns are in the following areas:” Source location 2021-0363-Response-from-CQC_Published
Open published response
27 Feb 2019 Theresa Margaret Feehan · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Inadequate recording and coding of relevant medical history on the active problem list View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Theresa Margaret Feehan · 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
Theresa Margaret Feehan, who had severe oxygen- and steroid-dependent allergic asthma, was found deceased at home on 12 March 2018. The court recorded aspiration pneumonia and ingestion of amitriptyline and dihydrocodeine as the medical cause of death, with natural causes combined with side effects of prescribed medication. Concerns included inadequate medication review, incomplete medical-history recording, poor correlation between medication and problem lists, insufficient systems for identifying harmful medication interactions, and inadequate supervision of administrative work.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate recording and coding of relevant medical history on the active problem list
Wider context from the report “2. That the recording and coding of relevant medical history on the active problem list is inadequate thus putting patients at risk
” Source location Theresa Margaret Feehan · Prevention of Future Deaths report
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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 Inspections ultimately found no concerns in the areas identified, so there was no basis for enforcement action.
Verbatim wording from the response “The provider made significant challenges to the findings we made. We accepted those challenges and decided there was no basis for us to take enforcement action. We also carried out a full and comprehensive rated inspection in June 2019. I attach copies of the reports of both of these inspections. They are also available on our website under the “All reports” link at https://www.cqc.org.uk/location/1-549237033.” Source location 2019-0070-Amended-Response-from-Care-Quality-Commission-Redacted
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18 Dec 2018 John Anthony Delahaye · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Unreliable recording of relevant past and current medical conditions View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Birmingham and Solihull Mental Health NHS Foundation Trust NHS England
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
Birmingham and Solihull Mental Health NHS Foundation Trust
Remind clinical staff in writing to check all relevant SystemOne record sections and use the search function when reviewing previous medical conditions.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Work with NHS England on national resolution of SystemOne read-coding inconsistencies.
View source
NHS England
Introduce SNOMED CT as the alternative coding system in prison general-practice SystmOne records.
View source
NHS England
Support health and justice users during the transition to SNOMED CT by working with NHS Digital and regional commissioners.
View source See 1 more action
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John Anthony Delahaye · 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 Anthony Delahaye was found dead in his cell at HMP Birmingham on 5 March 2018 after taking an insulin overdose. The report identified concerns about the clarity and use of medication risk assessments, incomplete medical records, the absence of healthcare involvement in ACCT reviews, and the failure to carry out a welfare check when his cell was unlocked.
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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 Unreliable recording of relevant past and current medical conditions
Wider context from the report “2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’ . Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
” Source location John Anthony Delahaye · 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 Remind clinical staff in writing to check all relevant SystemOne record sections and use the search function when reviewing previous medical conditions.
Verbatim wording from the response “summary and family history. However there are multiple read codes for conditions and they are not used consistently across the prison healthcare system nationally. System1 is a national system and is out of the local control of Birmingham and Solihull Mental Health NHS Foundation Trust. It is therefore recommended that this issue is highlighted by HM Coroner to NHS England for national resolution indeed we can see that this has been raised with NHSE as part of the same regulation 28 report. BSMHFT does however recognise that it could put some additional local controls in place to mitigate the risk associated with SystemOne and Read Codes and we are therefore implementing the following action as a provider of Healthcare in HMP Birmingham.” Source location 2018-0388-Responses
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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 Work with NHS England on national resolution of SystemOne read-coding inconsistencies.
Verbatim wording from the response “summary and family history. However there are multiple read codes for conditions and they are not used consistently across the prison healthcare system nationally. System1 is a national system and is out of the local control of Birmingham and Solihull Mental Health NHS Foundation Trust. It is therefore recommended that this issue is highlighted by HM Coroner to NHS England for national resolution indeed we can see that this has been raised with NHSE as part of the same regulation 28 report. BSMHFT does however recognise that it could put some additional local controls in place to mitigate the risk associated with SystemOne and Read Codes and we are therefore implementing the following action as a provider of Healthcare in HMP Birmingham.” Source location 2018-0388-Responses
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 Introduce SNOMED CT as the alternative coding system in prison general-practice SystmOne records.
Verbatim wording from the response “2. SystmOne Read Codes” Source location 2018-0388-Responses
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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 Support health and justice users during the transition to SNOMED CT by working with NHS Digital and regional commissioners.
Verbatim wording from the response “By way of background this concern is not limited to prison healthcare and exists across all primary care general practice settings. Historically there have been two clinical coding systems in use in general practice, with not all general practice systems using the same coding system causing inconsistency in coding. NHS Digital began rolling out a new mandated coding system called SNOMED CT coding from April 2018 to replace all other coding systems. The rollout schedule varies depending on the clinical system provider but will be complete by April 2020. SNOMED CT will provide a single clinical terminology, enabling clinical data to be exchanged accurately and consistently across all care settings. This will allow better patient care and improve how clinical data can be analysed and reported on.” Source location 2018-0388-Responses
Open published 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 Local trusts cannot alter SystmOne’s national read-coding system because it is outside their control.
Verbatim wording from the response “summary and family history. However there are multiple read codes for conditions and they are not used consistently across the prison healthcare system nationally. System1 is a national system and is out of the local control of Birmingham and Solihull Mental Health NHS Foundation Trust. It is therefore recommended that this issue is highlighted by HM Coroner to NHS England for national resolution indeed we can see that this has been raised with NHSE as part of the same regulation 28 report. BSMHFT does however recognise that it could put some additional local controls in place to mitigate the risk associated with SystemOne and Read Codes and we are therefore implementing the following action as a provider of Healthcare in HMP Birmingham.” Source location 2018-0388-Responses
Open published 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 National resolution of inconsistent SystmOne read coding is assigned to NHS England.
Verbatim wording from the response “summary and family history. However there are multiple read codes for conditions and they are not used consistently across the prison healthcare system nationally. System1 is a national system and is out of the local control of Birmingham and Solihull Mental Health NHS Foundation Trust. It is therefore recommended that this issue is highlighted by HM Coroner to NHS England for national resolution indeed we can see that this has been raised with NHSE as part of the same regulation 28 report. BSMHFT does however recognise that it could put some additional local controls in place to mitigate the risk associated with SystemOne and Read Codes and we are therefore implementing the following action as a provider of Healthcare in HMP Birmingham.” Source location 2018-0388-Responses
Open published response
4 Sep 2018 Collin Gary GRIFFITHS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to record medical conditions through a method independent of verbal communication 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. 3
Masta Limited
Test digital pads for storing patients’ signed confirmation that medical questions were understood and answered accurately.
View source
Masta Limited
Produce and finalize a pre-consultation medical-question fact sheet explaining the questions and their importance.
View source
Masta Limited
Provide clinics with a laminated copy of the medical questions for patients to review with nurses during risk assessments.
View source
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AI-generated summary
Collin Gary GRIFFITHS · 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
Collin Gary Griffiths received a yellow fever vaccination on 23 March 2018 despite having previously undergone a thymectomy for a thymoma, and subsequently died from yellow fever vaccine-associated viscerotropic disease and multi-organ failure. The concerns identified were reliance on verbal communication to record medical conditions and the lack of auditing of the accuracy of nurses’ records at the travel clinic.
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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 record medical conditions through a method independent of verbal communication
Wider context from the report “1. The recording of medical conditions was entirely dependent on the verbal communication , which in this instance was sub optimal.
Would there be anything to stop MASTA handing out a tick box questionnaire (similar to the ones for blood donors) for patients to fill in while they are waiting to be seen?
There seems to be a need for an added layer of security, rather than just relying on patients listening to a long list of conditions being read out.
” Source location Collin Gary GRIFFITHS · 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 Test digital pads for storing patients’ signed confirmation that medical questions were understood and answered accurately.
Verbatim wording from the response “• We are currently testing digital pads to obtain a written signature that can be stored in our bespoke medical records system. The intention is that this would be signed by the client once all the medical questions have been covered as a declaration that they have understood the questions asked and that they have read from the laminated question document.” Source location 2018-Response-by-Masta
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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 Produce and finalize a pre-consultation medical-question fact sheet explaining the questions and their importance.
Verbatim wording from the response “• We have written a fact sheet detailing all the medical questions that a traveler will be asked during the consultation and the reasons why the questions are important. This fact sheet will be emailed out to travelers before their consultation, along with the Travel Health Brief - please see enclosed document 3. This factsheet is currently going through final review stage before going live.” Source location 2018-Response-by-Masta
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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 clinics with a laminated copy of the medical questions for patients to review with nurses during risk assessments.
Verbatim wording from the response “• The clinics will be provided with the new medical questions in a laminated document to be given to travelers to read through with the nurse, as they go through their individual risk assessment, preventing any misunderstanding - please see enclosed document 4. The draft has been sent to the marketing team to format on the 26th October 2018” Source location 2018-Response-by-Masta
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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 patient-completed tick-box questionnaire is considered less effective because last-minute attendance and context-free questions may cause errors.
Verbatim wording from the response “We acknowledge that the coroner has suggested each patient complete a tick box questionnaire whilst waiting for their consultation. We do not feel this would be as effective as all the improvements detailed above. From experience patients turn up last minute for their appointments and would not therefore have the required time to digest and complete the medical questions. There is also the risk that questions without the context and ability to ask questions of a medical professional could lead to errors.” Source location 2018-Response-by-Masta
Open published response
15 Jun 2017 Mrs Lily Townsend · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1
Inadequate preoperative medical history-taking and recording View source
This report raised 4 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 Lily Townsend · 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 Lily Townsend fell at home, was admitted to hospital with a fractured neck of femur, and died during cemented hemiarthroplasty after her oxygen saturation and blood pressure fell rapidly. Concerns included inadequate recording of her medical history, failure to identify her as being at extremely high risk for major surgery, inadequate consent, and whether an un-cemented operation might have reduced the risks.
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 Inadequate preoperative medical history-taking and recording
Wider context from the report “1. Evidence emerged during the inquest that during the preoperative assessment inadequate medical history was taken and there was a failure to record her previous myocardial infarction, ischaemic heart disease and pulmonary hypertension .
2. She had severe cardiopulmonary disease and should have been considered as at extremely high risk for major surgery. This should have been discussed with the patient and her family before consent being given.
3. The risks of the procedure may have been reduced by performing an un-cemented operation given the known potential cardiopulmonary complications of cement.
4. The Trust initiated an internal investigation and identified that the root causes were:
a) Failure to use existing care bundle and failure to access information across different systems contributed to inadequate pre-operative assessment and failure to highlight patient as high risk.
b) Consent process inadequate.
” Source location Mrs Lily Townsend · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to capture important patient history at admission 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
Hope Erin Evans · 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
Hope Erin Evans, a premature baby born at 26 weeks, died from sepsis contributed to by ESBL E. coli contracted in hospital. The report states that the source was likely another baby, although the means of transfer was unknown. Concerns included important patient history not being captured and passed between hospitals, and the failure to complete All Wales Inter Hospital Transfer documentation.
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 capture important patient history at admission
Wider context from the report “1. I have concerns that important patient history was not captured by the admitting hospital and passed to the receiving hospital. Mother A had received IVF treatment in India and had there acquired the ESBL E. coli. This important information was recorded in her medical notes which were with her. If the receiving hospital was aware of this the certainly the treatment of the twins would have been different and barrier nursing would have been implemented.
” Source location Hope Erin Evans · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.