26 May 2022 Katie Julia WILKINS · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Unavailability of Haematologist capacity to address coagulopathy management needs View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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
Department of Health and Social Care
Review the distribution of medical specialty training posts and begin reallocating posts to support equitable workforce distribution.
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Department of Health and Social Care
Establish eight additional haematology training places as part of cancer and diagnostic workforce investment.
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Department of Health and Social Care
Fund 1,500 additional undergraduate medical school places annually for domestic students in England.
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Department of Health and Social Care
Commission a report on the long-term strategic drivers of workforce demand and supply.
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Department of Health and Social Care
Commission NHS England to develop a long-term workforce plan addressing workforce demand and supply.
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Department of Health and Social Care
Deliver initiatives to improve retention, wellbeing and career progression for doctors in training, including flexible training opportunities.
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Department of Health and Social Care
Analyse cancer call-for-evidence responses to develop a 10 Year Cancer Plan covering workforce requirements, including blood cancer.
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AI-generated summary
Katie Julia WILKINS · 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
Katie Julia WILKINS was a 14-year-old girl with acute promyelocytic leukaemia and associated coagulopathy who suffered a catastrophic intracerebral haemorrhage after fibrinogen concentrate was not administered in accordance with her treatment plan. She underwent decompressive surgery but did not recover and died on 31 July 2020. The principal concern was that management of coagulopathy in APML patients at Alder Hey Trust would continue to be led by Oncology Consultants rather than Haematologists, despite the serious bleeding risk.
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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 Unavailability of Haematologist capacity to address coagulopathy management needs
Wider context from the report “The inquest has highlighted an ongoing concern that Oncology Consultants will continue to be the lead Consultants for care of APML patients at Alder Hey Trust. The most significant risk of death in such patients is due to the risk of serious bleeding due to the associated and significant coagulopathy. Coagulopathy management should be led by a Haematologist to prevent future deaths due to this issue, that was recognised by a Consultant Haematologist who gave evidence to the inquest as a expert witness and as supported by a leading Haematologist at the Trust. There is a nationally a shortage of Haematologists which leaves Alder Hey Trust without resources available to them to address this matter of concern or to recruit .
” Source location Katie Julia WILKINS · 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 distribution of medical specialty training posts and begin reallocating posts to support equitable workforce distribution.
Verbatim wording from the response “Turning to the concern regarding a shortage of haematologists, whilst we have made some progress, we know that there is more to do on staffing within haematology departments in England. In August 2022, there were 953 full time equivalent consultants working in the specialty of haematology in NHS hospital trusts in England, which is an increase of 342 (55.9%) since August 2010. However, Health Education England and NHS England are working collaboratively to review the distribution of medical specialty training posts across the country.” Source location Response from Department of Health and Social Care
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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 Establish eight additional haematology training places as part of cancer and diagnostic workforce investment.
Verbatim wording from the response “In addition, haematology has seen a moderate expansion as part of investment in the cancer and diagnostic workforce in the last two years. An additional eight training places have been established beginning in 2022. With current planning, an extra four places are expected to be created in 2023 and in 2024 as part of cancer and diagnostic workforce growth.” Source location Response from Department of Health and Social Care
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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 Fund 1,500 additional undergraduate medical school places annually for domestic students in England.
Verbatim wording from the response “In addition to this, the Government has funded an additional 1,500 undergraduate medical school places each year for domestic students in England, a 25% increase over three years. The first graduates from this expansion entered foundation training in August this year. The Government is committed to ensuring that the number and distribution of medical school places are in line with England’s workforce requirements and continues to monitor the effectiveness of current arrangements.” Source location Response from Department of Health and Social Care
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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 Commission a report on the long-term strategic drivers of workforce demand and supply.
Verbatim wording from the response “To support long-term workforce planning, the Department has commissioned Health Education England to produce a report looking at the long-term strategic drivers of workforce demand and supply. Building on this work, the Department has also commissioned NHS England to develop a long-term workforce plan. The plan will build on the foundations of the NHS People Plan. NHS England is due to complete this work by the end of 2022 and the key conclusions will be shared in due course.” Source location Response from Department of Health and Social Care
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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 Commission NHS England to develop a long-term workforce plan addressing workforce demand and supply.
Verbatim wording from the response “To support long-term workforce planning, the Department has commissioned Health Education England to produce a report looking at the long-term strategic drivers of workforce demand and supply. Building on this work, the Department has also commissioned NHS England to develop a long-term workforce plan. The plan will build on the foundations of the NHS People Plan. NHS England is due to complete this work by the end of 2022 and the key conclusions will be shared in due course.” Source location Response from Department of Health and Social Care
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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 Deliver initiatives to improve retention, wellbeing and career progression for doctors in training, including flexible training opportunities.
Verbatim wording from the response “We are also taking action to increase the retention of doctors, including haematologists, and supporting them to progress into long-term careers. The Enhancing Junior Doctors’ Working Lives programme, led by Health Education England, is delivering a range of initiatives to improve the” Source location Response from Department of Health and Social Care
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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 Analyse cancer call-for-evidence responses to develop a 10 Year Cancer Plan covering workforce requirements, including blood cancer.
Verbatim wording from the response “Finally, the Department is currently analysing the responses received to the cancer call for evidence to develop the forthcoming 10 Year Cancer Plan. It will set out plans to ensure that the appropriate workforce is in place to support all cancer patients and the plan will address all cancer types, including blood cancer. Diagnostic checks are a key part of many elective care pathways, including cancer. £2.3bn was awarded at SR21 to transform diagnostic services over the next three years, including for non-specific symptoms like those with potential blood cancer.” Source location Response from Department of Health and Social Care
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23 Oct 2021 Margaret Kinsey · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Insufficient senior emergency department doctor staffing at night View source
This report raised 3 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
Margaret Kinsey · 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
Margaret Rose Kinsey, who had significant heart disease, was discharged from Stepping Hill Hospital Emergency Department on 11 December 2020 after presenting with shortness of breath and significant bilateral leg swelling. She collapsed at home the following day and died after attempts to resuscitate her were unsuccessful; post mortem examination found acute left ventricular failure caused by her underlying heart disease. The substantive concerns included limited overnight consultant cover, difficulties supervising an inexperienced junior doctor, and inconsistent documentation of clinical discussions and supervision.
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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 senior emergency department doctor staffing at night
Wider context from the report “1. The inquest heard that due to the time of her arrival in the Emergency Department on 11th December 2020 consultants were not on site . The most senior doctors available were middle grade and the number available at that time of night was significantly reduced . As a consequence the evidence was that supervision and support of junior doctors was very difficult given the demands on the middle grade doctors on site. This was exacerbated by the fact that on the evening Mrs Kinsey was admitted the FY doctors had just rotated. The FY2 who saw her had very limited post qualification experience of Emergency Medicine. The inquest heard that particularly at night time support and supervision of FY ED doctors presents significant challenges across the NHS in relation to patient care.
” Source location Margaret Kinsey · Prevention of Future Deaths report
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13 Jul 2021 Valmai Ann WEST · Prevention of Future Deaths report Gwent
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Concerns raised 1
Inadequate staffing levels for the full range of Emergency Department duties View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Valmai Ann WEST · 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
Valmai West suffered falls on 11 and 16 January 2020, was admitted to hospital after fracturing her pubic ramus, and was later found unresponsive with an extensive subdural haemorrhage. She died at the Royal Gwent Hospital on 22 January 2020. The concern identified was that Emergency Department staffing levels may have contributed to observations not being performed in accordance with hospital protocol and NICE guidance, potentially putting future patients at risk.
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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 staffing levels for the full range of Emergency Department duties
Wider context from the report “During the course of the inquest, consideration was given to the clinical decisions made in the Emergency Department of the Royal Gwent Hospital. I concluded that there was no evidence that Mrs West was displaying signs that would alert the staff to a possible intracranial bleed. However in evidence Dr ████████ Consultant in Emergency Medicine, acknowledged that the staff had not followed hospital protocol or the NICE guidance in relation to the frequency with which observations should be performed. Dr ████████ assessment of the situation was that this was probably caused by inadequate staff numbers to undertake the full range of duties required . She further stated that this is a frequent and ongoing problem in the Emergency Department .
Whilst this did not influence the outcome for Mrs West I am concerned that this may put the lives of future patients at risk.
” Source location Valmai Ann WEST · 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 Complete a review of Emergency Department nurse staffing levels following the Regulation 28 Report.
Verbatim wording from the response “Following receipt of the Regulation 28 Report a review of the nurse staffing levels was undertaken by the Senior Nurse Manager of the Emergency Department. I can confirm nurse staffing levels at the index time were appropriate and adequate and as per the roster for the area the patient was cared for. The staffing levels would not have impacted on the ability to undertake neurological observations.” Source location 2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_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 Complete an in-depth review of Emergency Department nurse staffing levels at Grange University Hospital, considering increased demand and relevant staffing guidance.
Verbatim wording from the response “I thought it would be helpful to share that an in-depth review of nurse staffing levels for the Emergency Department (ED) at the Grange University Hospital was commissioned as a result of the early opening of the hospital and in light of increased patient demand. This has been undertaken by the” Source location 2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
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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 Undertake a review of Emergency Department medical staffing alongside the nurse staffing review.
Verbatim wording from the response “Senior Nurse Manager for ED and the Assistant Head of Nursing, supported by the Deputy Director of Nursing. The assessment is based on RCN Guidance, RCEM Guidance, Nurse Staffing Levels (Wales) Act 2016 and, importantly, professional judgement. A similar review of medical staffing is also being undertaken.” Source location 2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
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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 Nurse staffing levels were adequate and did not prevent neurological observations.
Verbatim wording from the response “Following receipt of the Regulation 28 Report a review of the nurse staffing levels was undertaken by the Senior Nurse Manager of the Emergency Department. I can confirm nurse staffing levels at the index time were appropriate and adequate and as per the roster for the area the patient was cared for. The staffing levels would not have impacted on the ability to undertake neurological observations.” Source location 2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
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6 Apr 2020 George Townsend · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Insufficient GP capacity to see patients View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS Greater Manchester Integrated Care Board
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
NHS Greater Manchester Integrated Care Board
Gather workforce data and identify Trafford primary-care areas needing workforce-model support through the Primary Care Workforce Delivery Group.
View source
NHS Greater Manchester Integrated Care Board
Lead the Greater Manchester GP Retention Scheme to promote flexible working and support retention of general-practice clinicians.
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NHS Greater Manchester Integrated Care Board
Use 2020/21 Trafford funding to secure Basic Trainer Course placements for five GPs, increasing local training capacity.
View source
NHS Greater Manchester Integrated Care Board
Undertake a practice diagnostic and progress its resulting organisational action plan with the CCG’s primary-care leadership.
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AI-generated summary
George 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
George Townsend, who was receiving long-term antibiotic therapy, developed worsening diarrhoea and was later diagnosed in hospital with Clostridium difficile infection and pneumonia. He died at Trafford General Hospital on 30 August 2019 from multi-organ failure due to bronchopneumonia. The concerns included delayed GP assessment and testing, inadequate escalation from the nurse to a doctor, failure to recognise the risks associated with his health conditions, poor medical record-keeping, and longstanding concerns about GP practice capacity and oversight.
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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 GP capacity to see patients
Wider context from the report “1. The inquest heard that Mr Townsend should have seen a GP and had further tests prior to his admission to Salford Royal Hospital. The inquest heard that at the GP practice in question there were insufficient GPs to see patients . In addition there was no evidence of a clear escalation process from the Nurse to a Doctor within the practice.
” Source location George Townsend · 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 Gather workforce data and identify Trafford primary-care areas needing workforce-model support through the Primary Care Workforce Delivery Group.
Verbatim wording from the response “To offer further assurance around GP availability generally, the CCG has a Primary Care Workforce Delivery Group which has a remit to review current primary care workforce supply and demand in Trafford, and to make recommendations for improvement and sustainability, aligned to integrated commissioning principles. Some of its key actions include:” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
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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 Lead the Greater Manchester GP Retention Scheme to promote flexible working and support retention of general-practice clinicians.
Verbatim wording from the response “An example of an area of work undertaken by this group includes leading on the GM GP Retention Scheme which aims to facilitate initiatives to enable clinicians to stay in the workforce, through promoting new ways of working and providing a more flexible offer that will create a sustainable model within general practice. The CCG is keen to attract, train and retain clinical roles and so part of Trafford’s allocated funding for 2020/21 has been used to secure placements on the Basic Trainer Course for 5 Trafford GPs, increasing the number of training environments within the borough. This initiative not only provides placements for training clinicians but also supports the professional development of our existing workforce.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
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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 2020/21 Trafford funding to secure Basic Trainer Course placements for five GPs, increasing local training capacity.
Verbatim wording from the response “An example of an area of work undertaken by this group includes leading on the GM GP Retention Scheme which aims to facilitate initiatives to enable clinicians to stay in the workforce, through promoting new ways of working and providing a more flexible offer that will create a sustainable model within general practice. The CCG is keen to attract, train and retain clinical roles and so part of Trafford’s allocated funding for 2020/21 has been used to secure placements on the Basic Trainer Course for 5 Trafford GPs, increasing the number of training environments within the borough. This initiative not only provides placements for training clinicians but also supports the professional development of our existing workforce.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
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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 Undertake a practice diagnostic and progress its resulting organisational action plan with the CCG’s primary-care leadership.
Verbatim wording from the response “September 2018
Following meetings between Dr ████████ and the CCG’s Medical Director, Dr ████████ (MJ), Dr ████████ agreed for the CCG to undertake a “practice diagnostic”. The diagnostic took place on the 25th & 26th September 2018. The report made 14 recommendations, which were mainly organisational issues. The report concluded that the clinical care was generally safe and this was based on triangulating a number of nationally available data sources. The report also noted that the practices were offering more appointments per 1000 population than the evidence suggested, however the report advised Dr ████████ to appoint two additional full time GPs.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
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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 practice had slightly more GP appointments available than average, disputing that insufficient GP cover caused the concern.
Verbatim wording from the response “Whilst there are general guiding principles and different methodologies for calculating the number of GPs to cover the number of patients a practice has, GP cover varies from practice to practice. The earlier diagnostic workup that the practice had slightly more GP appointments available to patients than average.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
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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 CCG could not recruit additional GPs, appoint a caretaker or formally intervene because operational responsibility remained with the practice contract holder.
Verbatim wording from the response “inspections, Dr ████████ CQC registration was suspended from his Old Trafford contract meaning he would be unable to practice. In the case of GH his registration was not suspended meaning, whilst he could not practice he was still responsible for the day to day operational running of that practice, including the adequate clinical cover for patients registered at GH. The CCG were unable to intervene with recruiting with more GP’s and other support generally as this was the responsibility of Dr ████████ at that time.” Source location 2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
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2 Mar 2020 Mrs Ibiyemi Ereohah · Prevention of Future Deaths report East London
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Concerns raised 1
Insufficient gynae-oncology consultant cover 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
Mrs Ibiyemi Ereohah · 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 Ibiyemi Ereohah attended hospital with abdominal pain and anaemia, and investigations concerning a possible sarcoma were followed by delays and deficiencies in assessment and surgical planning. She underwent a hysterectomy on 30 August 2018 and was subsequently diagnosed with a high-grade uterine sarcoma; she died from metastatic leiomyosarcoma on 17 September 2018. The substantive concerns included inadequate gynae-oncology consultant cover and a delayed consultant review of her fitness for surgery.
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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 gynae-oncology consultant cover
Wider context from the report “1. Many of the concerns arising in this case were considered to be due to an insufficiency of gynae-oncology consultant cover at Newham University hospital . The lack of adequate Consultant cover was deemed to have contributed to the lack of advocacy at the MDT meeting; the inability to challenge the MDT conclusion and the lack of Consultant overview of the recurrent admissions . In July 2019, the Trust agreed two key actions to address this deficiency:
• Clinical Leads at the RLH and NUH to review gynaecological oncology staffing and job planning, to ensure adequate administration time; cover when on leave/programmed for other duties, such as hot weeks.
• There should be an urgent organisational development/service level review of the NUH gynae-oncology team that is independent of the site.
As at the date of the Inquest, neither of these necessary actions had been completed.
” Source location Mrs Ibiyemi Ereohah · Prevention of Future Deaths report
Open source report
Concerns raised 2
Insufficient radiology clinician staffing View source Lack of medical cover at the community hospital during out-of-hours admissions 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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Terence Douglas Thornton · 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
Terence Douglas Thornton was admitted to hospital after a fall in which he struck his head, while receiving warfarin. A subtle subdural haemorrhage was missed on the initial CT scan; after discharge and administration of enoxaparin, the haemorrhage expanded catastrophically and he died on 19 September 2017. The concerns included radiology staffing shortages and work pressures, with a consequent risk of similar fatalities.
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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 radiology clinician staffing
Wider context from the report “(1) At the Inquest I heard evidence from ████████ Clinical Director for Radiology at Derriford Hospital. He told me that, currently, there are 44 radiologists working within the Trust. He told me that he believed there was a need for up to a further 16 clinicians across a range of specialities .
(2) I also heard evidence from ████████ who felt that work pressures may have caused or contributed to the error that occurred in this instance .
(3) It is not the first time that shortages of radiology clinicians has been brought to my attention at Inquest. I am aware that there are difficulties in this regard nationally but I am concerned that the problems in Derriford appear to be worsening with the consequent risk that similar fatalities may occur in the future. In the circumstances, it is my duty to report this situation to you so that you may consider what action needs to be taken to address the situation.
” Source location Terence Douglas Thornton · 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 Lack of medical cover at the community hospital during out-of-hours admissions
Wider context from the report “BRIEF SUMMARY OF MATTERS OF CONCERN
(1) During the course of the Inquest, I heard evidence from ████████ at Liskeard community hospital. She gave evidence that when Mr Thornton was admitted from Derriford, he arrived without an E-discharge, a copy of his prescription chart or his prescribed medication. As he was admitted during a Sunday evening where there was no medical cover in the hospital, this created very real difficulties . The out of hours service had to be contacted for a doctor to attend . In the event, that Doctor refused to prescribe blood thinning medication and Mr Thornton did not receive any for nearly 24 hours notwithstanding his known history of DVTs. ████████ told me that this “happens frequently.”
(2) I also heard from Doctor Sant. He works in Liskeard hospital on Mondays and Fridays. On Mondays, he deals with patients who have had been admitted from Derriford over the course of the weekend. He told me in evidence that his “guess” was that between 5 – 10% of patients do not arrive with the correct paperwork or medication. He agreed with my suggestion that if this was allowed to continue it would inevitably result in the future with a patient suffering harm.
(3) I would be grateful if you would consider the process for discharging patients from Derriford to Liskeard community hospital particularly where that discharge occurs out of hours, on a Friday (before the weekend) or over the course of a weekend. You may feel that there is a need to ensure the process is more robust and that patients are not discharged without any of the e-discharge form, a copy of the prescription chart and any prescribed medication. You may feel that it would be sensible to audit compliance with these requirements to ensure that an efficient and effective discharge to a community hospital takes place.
” Source location Terence Douglas Thornton · 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 Increase the radiology establishment by four posts and further expand it.
Verbatim wording from the response “You were informed at the inquest at that time University Hospitals Plymouth NHS Trust had 6 consultant vacancies (out of an establishment of 44 consultants). Although one of those vacancies was for a Neuroradiologist, it was not a contributory factor to the incident. We can clarify that the 6 vacancies referred to were new posts and the department is planning to increase its establishment by a further 4 posts this year. When we benchmark ourselves against other similar Trusts we compare favourably with the number of radiologists in post and we are planning to further increase our establishment. As part of the organisation’s business planning process we review the estimated demand against our capacity to ensure that we have the correct number of radiologists.” Source location 2019-0114-Response-by-University-Hospitals-Plymouth-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 Review estimated radiology demand against capacity through business planning.
Verbatim wording from the response “You were informed at the inquest at that time University Hospitals Plymouth NHS Trust had 6 consultant vacancies (out of an establishment of 44 consultants). Although one of those vacancies was for a Neuroradiologist, it was not a contributory factor to the incident. We can clarify that the 6 vacancies referred to were new posts and the department is planning to increase its establishment by a further 4 posts this year. When we benchmark ourselves against other similar Trusts we compare favourably with the number of radiologists in post and we are planning to further increase our establishment. As part of the organisation’s business planning process we review the estimated demand against our capacity to ensure that we have the correct number of radiologists.” Source location 2019-0114-Response-by-University-Hospitals-Plymouth-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 vacant neuroradiologist post was not a contributory factor in the incident.
Verbatim wording from the response “You were informed at the inquest at that time University Hospitals Plymouth NHS Trust had 6 consultant vacancies (out of an establishment of 44 consultants). Although one of those vacancies was for a Neuroradiologist, it was not a contributory factor to the incident. We can clarify that the 6 vacancies referred to were new posts and the department is planning to increase its establishment by a further 4 posts this year. When we benchmark ourselves against other similar Trusts we compare favourably with the number of radiologists in post and we are planning to further increase our establishment. As part of the organisation’s business planning process we review the estimated demand against our capacity to ensure that we have the correct number of radiologists.” Source location 2019-0114-Response-by-University-Hospitals-Plymouth-NHS-Trust
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16 Jan 2019 George Foster Thompson · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Insufficient doctor staffing capacity for emergencies, clinical queries and home visits View source
Linked response
Highlands & Trafalgar Square Surgery
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
Highlands & Trafalgar Square Surgery
Maintain a protocol requiring home visits requested before closing to be completed after 18:30 when necessary.
View source
Highlands & Trafalgar Square Surgery
Provide cross-cover through two nearby practices, allowing clinicians to access the practice clinical system remotely during capacity pressures or emergencies.
View source
Highlands & Trafalgar Square Surgery
Deliver group resilience training focused on home visits, emergencies and testing staff knowledge of operational policies.
View source
Highlands & Trafalgar Square Surgery
Review protocols in light of the concerns raised.
View source
Highlands & Trafalgar Square Surgery
Arrange telephone triage training for the identified doctor through accredited third-party trainers.
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AI-generated summary
George Foster Thompson · 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
George Foster Thompson, who had multiple chronic health problems and lived in a residential care home, became unwell on 21 August 2018, deteriorated despite receiving antibiotics, and died in hospital on 23 August 2018. The substantive concern was that only one doctor was on duty at the practice, with no resource for a home visit that afternoon even if the doctor considered one indicated.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient doctor staffing capacity for emergencies, clinical queries and home visits
Wider context from the report “The evidence before the court was that, on the afternoon of 21st August 2018, there was only one doctor on duty for the practice as a whole . The evidence of the relevant clinician was that in addition to undertaking a (habitually) busy afternoon surgery, he was the only doctor available to deal with emergencies or clinical queries . In those circumstances and whilst the relevant clinician described his telephone call with the care home in terms of being a “triage” consultation, there was no resource in the practice for a home visit to be undertaken that afternoon even if considered indicated by the doctor .
” Source location George Foster Thompson · 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 Maintain a protocol requiring home visits requested before closing to be completed after 18:30 when necessary.
Verbatim wording from the response “3) The doctor in question finished afternoon surgery at 17:20, our surgery closed at 18:30. Attached is our home visit protocol. In devising our home visit protocol, we have taken advice from our LMC (local medical committee). It’s a grey area whether we need to visit patient after we closed at 18:30 and handover to our deputised out of hours service.” Source location 2019-0022-Response-by-H.T-Practice
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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 cross-cover through two nearby practices, allowing clinicians to access the practice clinical system remotely during capacity pressures or emergencies.
Verbatim wording from the response “There are two other layers of resilience that are unique to a group practice of our size. We have two other surgeries nearby that can lend support when our capacity is reached or in emergencies when we have staff sickness. Medlock Vale Medical Practice and King Street Medical Centre.” Source location 2019-0022-Response-by-H.T-Practice
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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 Deliver group resilience training focused on home visits, emergencies and testing staff knowledge of operational policies.
Verbatim wording from the response “We had a group training day on 19th July 2018. The day was dedicated to our group resilience with home visits and emergencies being the centre point of our training. We stress test our resilience and held a quiz to test our staff knowledge of our operational policies.” Source location 2019-0022-Response-by-H.T-Practice
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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 protocols in light of the concerns raised.
Verbatim wording from the response “We have reviewed our protocols in light of your letter and we feel that they are robust for the current team that we have in place. We continually review our working practices to reflect changes in work load, winter pressure, staff changes and sickness/emergencies as well as structural and systems failures.” Source location 2019-0022-Response-by-H.T-Practice
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 Arrange telephone triage training for the identified doctor through accredited third-party trainers.
Verbatim wording from the response “1) Arrange telephone triage training for the doctor in question. To be arranged by accredited third party trainers.” Source location 2019-0022-Response-by-H.T-Practice
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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 Three doctors were working on 21 August 2018, contrary to the concern that only one doctor was on duty.
Verbatim wording from the response “1) There was only 1 doctor on duty for the practice as a whole” Source location 2019-0022-Response-by-H.T-Practice
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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 afternoon was not habitually busy; the doctor saw nine patients and had six unused appointments, including three afternoon slots.
Verbatim wording from the response “2) The doctor in question stated he has habitually busy afternoon surgeries and was the only doctor to deal with emergencies and clinical queries” Source location 2019-0022-Response-by-H.T-Practice
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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 Home-visit resources were available: three GPs were available and only two morning visits were requested and completed.
Verbatim wording from the response “3) There was no resources available to deal with home visits on the afternoon of the 21/8/2018.” Source location 2019-0022-Response-by-H.T-Practice
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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 Existing home-visit protocols, triage, late-visit practice and cross-cover arrangements were considered sufficient for operational resilience.
Verbatim wording from the response “Regarding home visits. Most of our home visits are phoned through in the morning before 11am. These are shared out among the doctors on that day. All home visits requested are triaged by a GP to assess if the patient needed a home visit. If we conclude that a home visit is needed we will visit the patient. We have never turned down a visit that we felt needed visiting, it’s not in our culture or clinically safe to do so.” Source location 2019-0022-Response-by-H.T-Practice
Open published response
21 Aug 2018 Kiarah Faith Adora Allen · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Insufficient nursing and clinical staffing for very sick babies View source
Linked response
Birmingham Women'S and Children'S 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. 5
Birmingham Women'S and Children'S NHS Foundation Trust
Allocate nurses to specific babies on every shift and reinforce the allocation process through staff communications.
View source
Birmingham Women'S and Children'S NHS Foundation Trust
Implement the neonatal workforce plan and continue recruitment to restore staffing capacity.
View source
Birmingham Women'S and Children'S NHS Foundation Trust
Reconstruct and align the NICU e-roster with the workforce plan.
View source
Birmingham Women'S and Children'S NHS Foundation Trust
Move babies where possible to support the safest care, while embedding the practice fully.
View source
Birmingham Women'S and Children'S NHS Foundation Trust
Price the Vocera system for staff to summon colleague support.
View source See 2 more actions
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AI-generated summary
Kiarah Faith Adora Allen · 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
Kiarah Faith Adora Allen was born extremely prematurely and died after an inadvertent total parenteral nutrition fluid overload during a change of treatment, which led to severe metabolic complications and cardiac failure. The report identified unsafe staffing levels, failure to follow the correct procedure, and failure to learn from a previous similar incident. The principal concern was that staffing levels were insufficient when the neonatal unit was full.
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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 nursing and clinical staffing for very sick babies
Wider context from the report “1. I heard evidence in the inquest that at the time this incident occurred there were unsafe levels of nursing and clinical staff . The funding provided for nurses assumed the unit was only 85% full. Therefore when the unit was full, there were insufficient numbers of nurses and doctors . Consideration needs to be given to providing additional funding to enable the unit to be appropriately staffed for the very sick babies they care for.
” Source location Kiarah Faith Adora Allen · 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 Allocate nurses to specific babies on every shift and reinforce the allocation process through staff communications.
Verbatim wording from the response “• Action 2: Nurses are allocated to specific babies each shift.
o The nurse in charge (NIC) is allocating babies to nurse every shift. This is being reinforced through the staff weekly newsletter.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-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 Implement the neonatal workforce plan and continue recruitment to restore staffing capacity.
Verbatim wording from the response “• Action 5: A new workforce plan will be developed by the senior leadership in neonates.
o The workforce plan is live, but recovery through increased recruitment is on-going.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-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 Reconstruct and align the NICU e-roster with the workforce plan.
Verbatim wording from the response “• Action 24: Head of Nursing to complete and implement a NICU workforce plan.
o The Workforce plan is being implemented and the NICU e-roster has been reconstructed and aligned to the workforce plan.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-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 Move babies where possible to support the safest care, while embedding the practice fully.
Verbatim wording from the response “• Action 9: Previous shift NIC to review babies and move them where necessary.
o Within current practice, the NIC is moving babies where ever possible to permit the safest possible care, however this is not yet fully embedded.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-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 Price the Vocera system for staff to summon colleague support.
Verbatim wording from the response “• Action 13: Head of Nursing to price the vocera system for staff to be able to summon support from colleagues, if required.
o Pricing for Vocera for all clinical areas is a current on-going task.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Open published response
Concerns raised 1
Insufficient A&E Doctor staffing to cover patient needs View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Shrewsbury and Telford Hospital NHS Trust
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AI-generated summary
Patricia Violet PALIN · 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
Patricia Violet PALIN died on 2 October 2017 after presenting to hospital with sepsis and kidney damage. The report describes delayed recognition and treatment, including delayed antibiotics, absence of oxygen administration, failure to remove leg dressings for examination, and failure to follow sepsis guidelines. Concerns also included limited access to GP records, insufficient A&E doctor cover, and an unavailable prescribed antibiotic.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient A&E Doctor staffing to cover patient needs
Wider context from the report “2. During the evening of the 1st October 2017, there were only two A&E Doctors on duty (a third had telephoned in sick ). Too few Doctors were therefore on duty in general to cover patient needs and there did not seem to be in place a programme for trying to get a third Doctor to replace the Doctor who had telephoned in sick.
” Source location Patricia Violet PALIN · Prevention of Future Deaths report
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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 Short-notice Emergency Department staffing gaps cannot always be covered because of workforce fragility and limited available doctors and agency staff.
Verbatim wording from the response “The Trust does have a process in place for trying to backfill vacant shifts in the Emergency Department. At the first instance we will attempt to contact our own doctors via the Departmental Consultants or Medical Staffing representative making contact. We will also advertise via external agencies at the same time to ensure that every attempt is made to fill the gap. I attach a copy of the flow charts used to backfill vacant shifts.” Source location 2018-0183-Response-by-Shrewsbury-and-Telford-Hospitals-NHS-Trust
Open published response
28 Apr 2018 Catherine Burns · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 1
Delays in doctor assessment after triage View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Blackpool 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. 11
Blackpool Teaching Hospitals NHS Foundation Trust
Complete a capacity and demand review of Emergency Department nursing and medical staffing.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Prepare and submit a paper seeking approval for increased Emergency Department staffing establishment.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Continue substantive recruitment to staffing vacancies and provide safe day-to-day shift cover.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Identify, escalate and safely manage medical and nursing staffing gaps through governance arrangements.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Operate the Better Care Now programme to improve patient flow across the health system.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Develop and implement an Escalation and Surge Protocol with agreed escalation criteria and assigned actions.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Use the SAFER care bundle to improve ward patient management and discharge planning.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Introduce a centralised control room to improve operational management of patient flow.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Maximise Ambulatory Emergency Care pathways so suitable patients are managed outside the Emergency Department.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Introduce therapies in the Emergency Department to accelerate admission or discharge decisions.
View source
Blackpool Teaching Hospitals NHS Foundation Trust
Provide triage nurses at reception to improve streaming and fast initial assessment.
View source See 8 more actions
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AI-generated summary
Catherine Burns · 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
Catherine Burns was admitted to hospital with abdominal pain, deteriorated during a prolonged wait for medical assessment, suffered respiratory arrest, and died on 5 December 2017. The principal concerns were emergency department workload, delayed medical assessment, insufficient monitoring, and failure to recognise deterioration promptly, creating a risk of future deaths.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in doctor assessment after triage
Wider context from the report “I am concerned that staff were unable to provide the level of care to Catherine Burns that they would have liked to provide or which they felt was appropriate and that that this was due to the number of patients they were expected to care for. Consequently deterioration in her condition was not appreciated as quickly as it may otherwise have been.
I am concerned that even during an extremely busy shift for a patient to be triaged as requiring assessment by a doctor and for that patient to then not be seen by a patient for over five hours risks future deaths and especially if the nursing staff are not able to monitor the patient as regularly as they may prefer.
When giving consideration to writing a report to prevent future deaths Coroners are not limited to deaths which are felt to have been contributed to by the issue causing the Coroner some concern. As stated above the care afforded to Mrs Burns did not in my view alter the outcome for her but this should not prevent this report being written if I believe the duty upon me is met.
I received impressive evidence from a Sister whose role was to co-ordinate the assessment area. She explained that during the entirety of the shift the staff had been dealing with approximately one third more patients than when they are performing at what is usually regarded as full capacity. However this was not an isolated incident and this had been the position throughout December, January, and February and that it has remained an issue which is persisting and cannot be solely attributed to what is sometimes described as “winter pressures”.
It may well come as no surprise that the Emergency Department staff is facing these pressures and it may be that you feel that as a Trust you are doing all that you feel that you can to minimise the impact caused by the increased workload. Indeed I received helpful evidence during the inquest from the co-ordinator of the Emergency Department who explained that efforts have been made to review practices in order to make the system more efficient and hopefully be able to cope with over-capacity.
Nevertheless, I believe that I have a duty to write this letter because I feel that there is a risk of future deaths caused or contributed to by staff not having the time to assess and care for patients due to their workload meaning any potentially significant deterioration in a patient’s condition may go unrecognised or is under-appreciated and with serious consequences.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
” Source location Catherine Burns · 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 Complete a capacity and demand review of Emergency Department nursing and medical staffing.
Verbatim wording from the response “In response to the increase in demand on ED, the Emergency Department has undertaken a capacity and demand review of nursing and medical staffing and found that an increase in establishment is required. Accordingly, a paper has been prepared and submitted to the Executive Team for consideration.” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Prepare and submit a paper seeking approval for increased Emergency Department staffing establishment.
Verbatim wording from the response “In response to the increase in demand on ED, the Emergency Department has undertaken a capacity and demand review of nursing and medical staffing and found that an increase in establishment is required. Accordingly, a paper has been prepared and submitted to the Executive Team for consideration.” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Continue substantive recruitment to staffing vacancies and provide safe day-to-day shift cover.
Verbatim wording from the response “Until such time as an increase in establishment has been agreed, the Department continues to recruit substantively to vacancies and cover staffing safely on a day to day, shift by shift basis. There are robust governance structures in place to ensure that both medical and nursing staffing gaps are identified early, escalated and managed safely.” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Identify, escalate and safely manage medical and nursing staffing gaps through governance arrangements.
Verbatim wording from the response “Until such time as an increase in establishment has been agreed, the Department continues to recruit substantively to vacancies and cover staffing safely on a day to day, shift by shift basis. There are robust governance structures in place to ensure that both medical and nursing staffing gaps are identified early, escalated and managed safely.” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Operate the Better Care Now programme to improve patient flow across the health system.
Verbatim wording from the response “The Better Care Now programme led by myself as Medical Director is in place to improve patient flow through the whole health system. As this programme begins to deliver, the pressure of overcrowding in the Emergency Department will begin to ease.” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Develop and implement an Escalation and Surge Protocol with agreed escalation criteria and assigned actions.
Verbatim wording from the response “As part of that programme of work, the Department is developing an Escalation and Surge Protocol to help coordinate a consistent and effective response to an increase in demand. The criteria for escalation has been agreed and includes an escalation in the wait to be seen. Actions are being assigned to support the nurse and doctor in charge of the Emergency Department to manage the pressure effectively and gain the support required to de-escalate. Escalation is being assessed through two hourly Safety Huddles and six times daily at bed meetings.” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Use the SAFER care bundle to improve ward patient management and discharge planning.
Verbatim wording from the response “Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Introduce a centralised control room to improve operational management of patient flow.
Verbatim wording from the response “Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Maximise Ambulatory Emergency Care pathways so suitable patients are managed outside the Emergency Department.
Verbatim wording from the response “Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Introduce therapies in the Emergency Department to accelerate admission or discharge decisions.
Verbatim wording from the response “Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Provide triage nurses at reception to improve streaming and fast initial assessment.
Verbatim wording from the response “Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.