Recurring concern

Unreliable pre-operative preparation and safety checks

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First reported 19 Dec 2013•Latest report 17 Jan 2018

Definition

What this concern includes

Includes failures of pre-operative preparation and safety-check arrangements, including patient preparation, inspection and functional checks of operating-theatre equipment, staff competence for those checks, and assurance or audit that required checks are completed.

Not included

Excludes deficiencies limited to intra-operative treatment, surgical technique or post-operative care.
Excludes the separate assessment of surgical suitability or operative risk where no failure of pre-operative preparation or safety checking is identified.
Excludes generic staff training, auditing or equipment-maintenance concerns not directly tied to pre-operative preparation or safety checks.
Excludes failures in unrelated clinical preparation or diagnostic processes.

Reports: 3
Individual concerns: 4
Date range: 2013–2018
Stated actions: 7

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

East Sussex Healthcare NHS Trust1

Eschmann Holdings Limited1

Medicines and Healthcare products Regulatory Agency1

Stockport NHS Foundation Trust1

University Hospitals Sussex NHS Foundation Trust1

Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

17 Jan2018
Brighton and Hove
Concerns raised1
1. Lack of pre-operative preparation
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review and circulate updated cystectomy pathway documentation covering enhanced recovery, patient information and discharge requirements.
  Stated by East Sussex Healthcare NHS TrustStated planned
2. Action
  Use the cystectomy pathway documentation for all relevant surgical cases.
  Stated by East Sussex Healthcare NHS TrustStated planned
Respondent positions 1
1. Position
  Pre-operative preparation occurred through assessment by a nurse and consultant anaesthetist; the concern that no preparation occurred is disputed.
  Stated by East Sussex Healthcare NHS TrustDisputes the concern
AI-generated summary

Barry John TUCKER · 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

The supplied text does not describe the circumstances of Barry John TUCKER’s death beyond recording that an inquest took place. Concerns included lack of pre-operative preparation and senior clinical input, absent enhanced-recovery support and information, inadequate hospital notes, flawed ambulance recall arrangements, and no coherent discharge-planning protocol for enhanced-recovery urology procedures.

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
Lack of pre-operative preparation
Wider context from the report
“(1) Mr. Tucker received no pre-op preparation. ”
Source location
Barry John TUCKER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review and circulate updated cystectomy pathway documentation covering enhanced recovery, patient information and discharge requirements.

Verbatim wording from the response
“Trust Response There is a care pathway document for Cystectomy patients which contains detailed discharge planning information, including prompts and checks which assist in documenting the key stages of the post-operative period and plan of care. That care pathway documentation was not used and the nursing and medical notes do not contain a great deal of detail of Mr Tucker’s post-operative progress. The Trust acknowledges the learning opportunity presented here and has implemented the action plan below.”

Source location
2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 5 · response
Published 8 March 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Use the cystectomy pathway documentation for all relevant surgical cases.

Verbatim wording from the response
“Recommendation: The Cystectomy Pathway patient documentation must be updated and used for all surgical cases no matter what ward to include the latest Cystectomy Enhanced Recovery Preparation Event and Recovery Pathway (CEPER) guidance and ensure clear to what patient information is provided and when (with sign off to state completed) and the discharge process/requirements;”

Source location
2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 5 · response
Published 8 March 2018
Open published response
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
Pre-operative preparation occurred through assessment by a nurse and consultant anaesthetist; the concern that no preparation occurred is disputed.

Verbatim wording from the response
“(1) Mr Tucker received no pre-op preparation”

Source location
2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 3 · response
Published 8 March 2018
Open published response
20 Jun2016
Manchester South
Concerns raised1
1. Failure to provide usable sterile surgical kits
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Proceeding with surgery when instrument-tray sterility was uncertain was unacceptable, requiring postponement until safe equipment was available.
  Stated by Stockport NHS Foundation TrustUnable to act
AI-generated summary

Michael Guy Hutchence · 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

Michael Guy Hutchence broke his lower leg after slipping on an icy pavement and died in hospital on 28 January 2016. The report raised concerns about repeated ward moves, staffing and record-keeping, weight-based anticoagulant dosing and inconsistent weight recording, inadequate equipment for leg elevation, and delays to surgery after two operation kits were found to be non-sterile. The stated medical cause of death included bronchopneumonia, deep vein thrombosis and pulmonary embolus, and fractured tibia and fibula.

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 provide usable sterile surgical kits
Wider context from the report
“7. The patient was taken to theatre for the operation and this could not be started as the “kit” for the operation was found to have a non-sterile status as the outer wrapping had been breached. The operation was delayed whilst another kit was obtained but this was also found to be defective. The operation was then aborted and put off for a further two days, during which time the patient was immobile and the risk of DVT and PE was inevitably increased. ”
Source location
Michael Guy Hutchence · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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
Proceeding with surgery when instrument-tray sterility was uncertain was unacceptable, requiring postponement until safe equipment was available.

Verbatim wording from the response
“Mr. Hutchence was scheduled for surgery on the trauma list for open reduction and internal fixation of fractured left tibia and fibula on 19th January 2016. It has not been possible to identify a particular cause for the breaches in the wrappings. Great care and attention is given to maintaining the integrity and sterility of the instrument tray wrappings. It is standard theatre practice that careful and thorough checking of every instrument tray wrapping is undertaken by the theatre practitioner prior to use. In this case, the routine checking identified the breaches and an appropriate action was taken to re-sterilise the instrument trays.”

Source location
2016-0228-Response-by-Stockport-NHS-Trust
Page 3 · response
Published 20 June 2016
Open published response
19 Dec2013
Manchester West
Concerns raised2
1. Inadequate staff training and auditing of pre-operative equipment checks
2. Pre-operation checks failing to assess handset function, condition, seals and position
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Implement and disseminate a theatre-preparation procedure requiring operating-table checks before daily lists.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completed
2. Action
  Implement a daily checklist for critical equipment across all theatres, with sign-off and monthly auditing.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completed
3. Action
  Review the theatre-preparation procedure to extend it to Wrightington Theatres.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated in progress
1. Action
  Establish a theatre-staff training system and matrix covering medical-device competence, compliance records, assessments and manufacturer guidance.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completed
2. Action
  Develop and complete safety checks of all operating tables using Trust checklists based on manufacturer manuals.
  Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completed
AI-generated summary

Kenneth Smalley · 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

Kenneth Smalley died after surgery to remove an infected aortic graft and repair an aortoduodenal fistula. During the surgery, an operating table moved uncontrollably and its emergency stop button did not work; later, bleeding from splenic lacerations required a splenectomy, and he deteriorated and died. Concerns included the safety, inspection, maintenance, positioning and checking of operating-table handsets, staff training and auditing, and the sharing of investigation findings between relevant organisations.

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 staff training and auditing of pre-operative equipment checks
Wider context from the report
“(2) I have concerns with regard to the Wrightington, Wigan & Leigh NHS Foundation Trust in relation to i) The function of operating tables and handsets particularly the review of all operating tables and handsets used at the Hospital following the incident on the 27th March 2013. ii) Pre-operation checks of equipment particularly the function of handsets attached to operating tables with particular attention to the general condition of the handsets, the seals, and the position of the handsets at the side of the operating table to avoid the handsets being placed on the floor of the Operating Theatre to reduce the risk of fluid ingress. iii) The procedures relating to inspection of operating tables and handsets used at the Hospital particularly to identify any damage to the handsets to ensure the immediate replacement of any damaged handsets. iv) The training of staff in relation to pre-operative checks of equipment in the operating theatres at the Hospital with emphasis on operating tables and handsets including the correct positioning of the handsets with effective auditing of such inspections. ”
Source location
Kenneth Smalley · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Pre-operation checks failing to assess handset function, condition, seals and position
Wider context from the report
“(2) I have concerns with regard to the Wrightington, Wigan & Leigh NHS Foundation Trust in relation to i) The function of operating tables and handsets particularly the review of all operating tables and handsets used at the Hospital following the incident on the 27th March 2013. ii) Pre-operation checks of equipment particularly the function of handsets attached to operating tables with particular attention to the general condition of the handsets, the seals, and the position of the handsets at the side of the operating table to avoid the handsets being placed on the floor of the Operating Theatre to reduce the risk of fluid ingress. iii) The procedures relating to inspection of operating tables and handsets used at the Hospital particularly to identify any damage to the handsets to ensure the immediate replacement of any damaged handsets. iv) The training of staff in relation to pre-operative checks of equipment in the operating theatres at the Hospital with emphasis on operating tables and handsets including the correct positioning of the handsets with effective auditing of such inspections. ”
Source location
Kenneth Smalley · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement and disseminate a theatre-preparation procedure requiring operating-table checks before daily lists.

Verbatim wording from the response
“A Standard Operating Procedure for the preparation of Theatres prior to commencement of their daily list was ratified and disseminated in December 2013. Checks on the theatre tables must be performed as part of this SOP.”

Source location
2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
Page 2 · response
Published 19 December 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a daily checklist for critical equipment across all theatres, with sign-off and monthly auditing.

Verbatim wording from the response
“In addition we have developed a daily checklist for all critical equipment, in all theatres across the trust, which must be signed by the person performing the checks and audited on a monthly basis. The disciplinary procedure for non compliance is quite clear within the ‘Preparation of RAEI & Leigh Theatres SOP’. This policy is currently under review to include Wrightington Theatres.”

Source location
2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
Page 2 · response
Published 19 December 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the theatre-preparation procedure to extend it to Wrightington Theatres.

Verbatim wording from the response
“In addition we have developed a daily checklist for all critical equipment, in all theatres across the trust, which must be signed by the person performing the checks and audited on a monthly basis. The disciplinary procedure for non compliance is quite clear within the ‘Preparation of RAEI & Leigh Theatres SOP’. This policy is currently under review to include Wrightington Theatres.”

Source location
2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
Page 2 · response
Published 19 December 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish a theatre-staff training system and matrix covering medical-device competence, compliance records, assessments and manufacturer guidance.

Verbatim wording from the response
“We have reviewed our staff training and now have a more robust system and matrix for training theatre staff maintaining records of training compliance. Building on the self assessment packs developed within the Trust for medical devices we have expanded our data base within theatres to cover all medical devices including medium and low risk items. Staff are assessed on competence and knowledge of devices and further training given as required. The medical device packs also include manufacturer’s user instructions and cleaning instructions.”

Source location
2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
Page 3 · response
Published 19 December 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and complete safety checks of all operating tables using Trust checklists based on manufacturer manuals.

Verbatim wording from the response
“The Trust has four different types of powered operating theatre tables in use and a total of twenty-four units. All theatre tables are maintained via external maintenance contracts. Since this incident, the Trust has developed its own checklist for each type of table based on the Manufacturers User Manuals. The Trusts own qualified Medical Engineering Technicians have undertaken thorough checks of all operating tables against these checklists to confirm their safety for use. The completed checklists will be attached to work orders as evidence of the findings should remedial actions be required.”

Source location
2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
Page 2 · response
Published 19 December 2013
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of pre-operative preparation

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to provide usable sterile surgical kits

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Inadequate staff training and auditing of pre-operative equipment checks

Pre-operation checks failing to assess handset function, condition, seals and position

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Actions described in response 2

Respondent positions 1

Respondent positions 1

Actions described in response 5