25 Jun 2026 KERRY TERESA SINGH · Prevention of Future Deaths report City of London
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Concerns raised 1
Lack of timely tertiary-centre involvement in care planning for patients requiring pacemaker lead extraction View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
East Kent Hospitals University 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. 4
East Kent Hospitals University NHS Foundation Trust
Implement the revised Devices MDT governance documents, including referral criteria, clinical reasoning, patient involvement, escalation and action-accountability requirements.
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East Kent Hospitals University NHS Foundation Trust
Apply the strengthened MDT governance model, where appropriate, to other Cardiology Service MDTs.
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East Kent Hospitals University NHS Foundation Trust
Maintain a centralised Devices MDT action log with named responsibility, completion dates, status tracking and escalation of outstanding actions.
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East Kent Hospitals University NHS Foundation Trust
Review implementation of the revised abnormal-results escalation process and compliance with completion of Devices MDT actions through governance arrangements.
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KERRY TERESA SINGH · 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
Kerry Teresa Singh died on 14 July 2025 after urgent extraction of a failing pacemaker lead caused a tear to the superior vena cava, severe bleeding and unsuccessful resuscitation. The report identified delays in involving a tertiary centre, failures to review a critical test result and complete a referral, inadequate systems for patient involvement and task monitoring, and a lack of internal investigation or review.
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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 timely tertiary-centre involvement in care planning for patients requiring pacemaker lead extraction
Wider context from the report “1. Although the need for pacemaker lead extraction at some point was recognised by 2019 at the latest, and although the procedure would necessarily be performed in a tertiary centre, no tertiary centre was consulted or involved in relevant care planning prior to the Deceased’s death ; there was no such involvement in 2021, when a decision was made to change the pacemaker battery but not the leads, and there was no such involvement subsequently, as the Deceased’s condition deteriorated.
2. The evidence I heard from St. Bartholomew’s Hospital was that it is important that the tertiary centre is aware of such patients at any early stage , as this provides an opportunity for the specialist team to understand fully the patient’s precise situation, and to plan for an elective procedure to be performed in a timely manner. I heard that the team at St. Bartholomew’s Hospital has such early involvement with the hospitals from which referrals are routinely received (which does not include the William Harvey Hospital).
3. I am concerned that the lack of timely involvement of the relevant tertiary centre in care planning may result in future deaths.
” Source location KERRY TERESA SINGH · 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 Implement the revised Devices MDT governance documents, including referral criteria, clinical reasoning, patient involvement, escalation and action-accountability requirements.
Verbatim wording from the response “Following the inquest into Mrs Singh’s death, the Terms of Reference for the Devices MDT were formally reviewed and ratified. A Standard Operating Procedure (“SOP”) has also been developed and implemented.” Source location Response from East Kent Hospitals University NHS Foundation 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 Apply the strengthened MDT governance model, where appropriate, to other Cardiology Service MDTs.
Verbatim wording from the response “The revised governance documents define the purpose and scope of the MDT, responsibilities of attendees, referral criteria, arrangements for recording clinical reasoning and communicating outcomes, circumstances in which tertiary advice should be sought, and the process for allocating, monitoring and escalating MDT actions.” Source location Response from East Kent Hospitals University NHS Foundation 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 Maintain a centralised Devices MDT action log with named responsibility, completion dates, status tracking and escalation of outstanding actions.
Verbatim wording from the response “Although actions arising from MDT discussions were historically recorded on individual referral documentation, the Cardiology Service has now introduced a centralised MDT action log.” Source location Response from East Kent Hospitals University NHS Foundation 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 implementation of the revised abnormal-results escalation process and compliance with completion of Devices MDT actions through governance arrangements.
Verbatim wording from the response “Actions agreed through the Devices MDT are now recorded on a central action log, with a named responsible individual and target completion date. Outstanding or overdue actions are reviewed through the MDT process and escalated where necessary. This includes tertiary-centre referrals, investigations, consultant review, changes to follow-up and communication with patients. Where tertiary referral is agreed, completion is confirmed by evidence that the referral has been submitted and recorded.” Source location Response from East Kent Hospitals University NHS Foundation 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 specialist extraction centre, in consultation with the patient, makes the final decision about whether and when lead extraction occurs.
Verbatim wording from the response “The final decision about whether and when to undertake extraction is made by the specialist extraction centre in consultation with the patient. The local Cardiology Service is, however, responsible for ensuring that the patient’s concerns and preferences are heard, documented and considered when determining whether specialist advice or referral is required.” Source location Response from East Kent Hospitals University NHS Foundation Trust
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6 May 2026 Lisa Jayne Townsend · Prevention of Future Deaths report South Wales Central
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Concerns raised 2
Lack of an established protocol for escalation and referral of HPB-related matters to a tertiary centre View source Delays in seeking specialist advice and transferring patients to a tertiary centre View source
Linked responses
Cwm Taf Morgannwg University Local Health Board The Health Board Welsh Government
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Cwm Taf Morgannwg University Local Health Board
Require early consultant-to-consultant referral to the University Hospital of Wales HPB team for specialist advice and transfer decisions.
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Welsh Government
Share lessons from the case with other health boards to inform their inter-hospital pathway arrangements.
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The Health Board
Reinforce the expectation of early consultant-level discussion for suspected bile duct injury and complex benign HPB cases.
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The Health Board
Remind relevant partners to use the existing HPB escalation framework, designated contacts and urgent advice procedures, and consider timely transfer.
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The Health Board
Use focused communication and education to reinforce referral and escalation principles for suspected bile duct injury.
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The Health Board
Develop and disseminate a formal regional escalation and referral framework specifying triggers, discussion timescales, contacts and transfer expectations.
View source
The Health Board
Embed learning through clinical governance, oversee implementation of revised escalation arrangements, confirm communication, and test compliance through audit or case review.
View source
Cwm Taf Morgannwg University Local Health Board
Transfer indicated patients promptly to the University Hospital of Wales HPB team and coordinate timely acceptance while avoiding unnecessary delays.
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Lisa Jayne 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
Lisa Jayne Townsend had abdominal pain and was diagnosed with cholecystitis and pancreatitis in late September 2024. Her gallbladder surgery was delayed and, during the operation on 1 October 2024, an injury was sustained to the bile duct; subsequent attempts to rectify it were unsuccessful. She later developed chronic sepsis and died on 20 March 2025. The report identified multiple delays and issues in her care, including the bile duct injury, as contributing to her death.
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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 an established protocol for escalation and referral of HPB-related matters to a tertiary centre
Wider context from the report “During the inquest touching the death of Lisa Jayne Townsend, the Coroner heard evidence in respect of the absence of clear guidance and protocol for when a referral should be made by the local hospital (Princess of Wales, Bridgend) to the tertiary centre (University Hospital of Wales) in respect of Hepato-Pancreato-Biliary (HPB) related matters . There was a delay in advice being sought from and transfer to the tertiary centre taking place. There remains no established protocol to assist Clinicians with when they should escalate and seek further specialist advice from their tertiary centre to ensure timely consideration of the patient’s issue.
” Source location Lisa Jayne Townsend · 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 Delays in seeking specialist advice and transferring patients to a tertiary centre
Wider context from the report “During the inquest touching the death of Lisa Jayne Townsend, the Coroner heard evidence in respect of the absence of clear guidance and protocol for when a referral should be made by the local hospital (Princess of Wales, Bridgend) to the tertiary centre (University Hospital of Wales) in respect of Hepato-Pancreato-Biliary (HPB) related matters. There was a delay in advice being sought from and transfer to the tertiary centre taking place. There remains no established protocol to assist Clinicians with when they should escalate and seek further specialist advice from their tertiary centre to ensure timely consideration of the patient’s issue.
” Source location Lisa Jayne 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 Require early consultant-to-consultant referral to the University Hospital of Wales HPB team for specialist advice and transfer decisions.
Verbatim wording from the response “We have now changed our pathway and follow up for patients with this complication. Please see the new guidelines of clinicians as set out below.” Source location Response from Cwm Taf Morganwg University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share lessons from the case with other health boards to inform their inter-hospital pathway arrangements.
Verbatim wording from the response “As a result, the NHS in Wales has undertaken appropriate and proportionate action in response to your report findings and I hope this resolves your concern. My officials will also ensure the lessons relating to this case are shared with other health boards to inform their pathway arrangements.” Source location Response from Cabinet Secretary for Health and Social Care in Wales, Welsh Government
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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 Reinforce the expectation of early consultant-level discussion for suspected bile duct injury and complex benign HPB cases.
Verbatim wording from the response “In response to the concern identified, the Health Board has reviewed the issues raised in relation to regional escalation to specialist HPB services. Immediate work has been undertaken to reinforce the existing expectation that suspected bile duct injury and comparable complex benign HPB cases should trigger early consultant-level discussion with the tertiary HPB centre at the point of suspicion, including where concern arises intra-operatively or in the post-operative period. This aligns with the emphasis in your current draft on early identification, timely specialist consultation and appropriate transfer.” Source location Response from Cardiff and Vale University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind relevant partners to use the existing HPB escalation framework, designated contacts and urgent advice procedures, and consider timely transfer.
Verbatim wording from the response “The Health Board has also taken steps to remind relevant partners of the existing escalation framework for HPB complications, including the need for urgent advice to be sought promptly and for transfer to be considered without avoidable delay where specialist tertiary management is indicated. As reflected in the current draft, this includes reinforcing designated contact avenues, urgent advice procedures and the importance of timely escalation.” Source location Response from Cardiff and Vale University Health Board
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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 Use focused communication and education to reinforce referral and escalation principles for suspected bile duct injury.
Verbatim wording from the response “In addition, focused communication and educational activity is being used to reinforce the existing clinical principles underpinning referral and escalation for suspected bile duct injury. The purpose of this action is to reduce unwarranted variation in practice, strengthen clinician awareness of when specialist input should be sought, and support more reliable application of recognised standards across organisational boundaries.” Source location Response from Cardiff and Vale University Health Board
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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 Develop and disseminate a formal regional escalation and referral framework specifying triggers, discussion timescales, contacts and transfer expectations.
Verbatim wording from the response “To address the Coroner’s concern more explicitly and transparently, the Health Board proposes further work to move from reliance on recognised but partly informal arrangements to a more clearly documented regional framework. This will include the development and dissemination of a formalised escalation and referral framework for suspected bile duct injury and other relevant complex benign HPB pathology, setting out referral triggers, expected timescales for consultant-to-consultant discussion, contact arrangements, and expectations regarding transfer where tertiary management is required. This builds directly on the current draft’s commitment to improve clarity and consistency through more formal frameworks. The Health Board also intends to continue engagement with regional partners, Welsh Government and relevant commissioning bodies regarding the current service model.” Source location Response from Cardiff and Vale University Health Board
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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 Embed learning through clinical governance, oversee implementation of revised escalation arrangements, confirm communication, and test compliance through audit or case review.
Verbatim wording from the response “The Health Board will additionally ensure that the learning from this case is embedded through governance processes, with oversight of implementation through the appropriate clinical governance structure, including confirmation that the revised escalation arrangements have been communicated and that compliance can be tested through audit or case review. This expands the assurance language already present in your draft that the Health Board remains committed to enhancing educational initiatives and reinforcing assurance processes.” Source location Response from Cardiff and Vale University Health Board
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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 Transfer indicated patients promptly to the University Hospital of Wales HPB team and coordinate timely acceptance while avoiding unnecessary delays.
Verbatim wording from the response “We have now changed our pathway and follow up for patients with this complication. Please see the new guidelines of clinicians as set out below.” Source location Response from Cwm Taf Morganwg University Health Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing health board actions to improve clinical understanding, referral and inter-hospital transfer arrangements are considered appropriate and proportionate to resolve the concerns.
Verbatim wording from the response “I note that both health boards named in your report have now responded. These responses outline the steps each organisation has taken to improve understanding among the clinical teams about the delivering this pathway of care. Both health boards have also reported what action they have taken to improve referral and transfer arrangements between their organisations.” Source location Response from Cabinet Secretary for Health and Social Care in Wales, Welsh Government
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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 Established clinical standards provide guidance; the principal failure was inconsistent application, not absence of specialist knowledge or access.
Verbatim wording from the response “The Health Board accepts that, in this case, there was delay in escalation from the treating Health Board ensuring referral for specialist HPB input, and it acknowledges the importance of ensuring greater clarity and consistency in regional referral arrangements for patients with suspected bile duct injury and other complex benign HPB pathology. At the same time, the Health Board considers it important to distinguish between a lack of clinical principles and a lack of formal commissioning arrangements. The management of suspected bile duct injury is guided by established national and international clinical standards which support early recognition, prompt discussion with a specialist HPB centre at the point of suspicion, and transfer where required for definitive expert management. These principles are embedded in surgical training and are recognised as standard practice.” Source location Response from Cardiff and Vale University Health Board
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16 Jun 2022 James Joseph MANNING · Prevention of Future Deaths report West Sussex
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Concerns raised 2
Lack of guidance for urgent referral of children to hospital or tertiary care View source Delays in reassessment and referral of urgent cases due to inadequate cover View source
This report raised 12 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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James Joseph MANNING · 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
James Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.
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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 guidance for urgent referral of children to hospital or tertiary care
Wider context from the report “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment. In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care ; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide.
” Source location James Joseph MANNING · 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 Delays in reassessment and referral of urgent cases due to inadequate cover
Wider context from the report “c) I heard evidence that at some points in James’s medical care there were delays in being reassessed especially following the sleep study . The delay in being reassessed and referred to tertiary care was contributed to by medical staff being off leave. Doctors will inevitably have leave yet I am still concerned that systems in place at that time were not sufficiently robust to ensure suitable cover was in place to progress urgent cases .
” Source location James Joseph MANNING · Prevention of Future Deaths report
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8 Jun 2022 Jack HURN · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to make timely VITT specialist referral and transfer arrangements View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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Jack HURN · 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
Jack Hurn, aged 26, died after developing vaccine-induced immune thrombocytopenia and thrombosis with cerebral venous sinus thrombosis following an AstraZeneca COVID-19 vaccination. Concerns included the absence or non-use of guidance and pathways for timely specialist management of VITT, aspects of his care at Alexandra Hospital, and the apparent inadequacy of the investigation into his care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make timely VITT specialist referral and transfer arrangements
Wider context from the report “1. The Level Two Comprehensive Investigation of the Worcestershire Acute Hospitals NHS Trust ("WAH") concluded the root cause of Jack's death was: "There was no official national guidance and no approved Trust guidance on managing VITT in place at the time this patient was admitted to AGH, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB)." The following care and service delivery problems were identified: “There was no written Trust or national guidance on managing VITT at the time the patient was admitted, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB).” The following Contributory factors were identified: - The Neurosurgical team at QEHB were contacted for advice; had the Trust VITT guidance been in place at the time, it would have stipulated not to contact the Neurosurgical team, but instead to contact Haematology and Neurology at QEHB.
- The Neurosurgical team at QEHB advised to continue medical management locally (at WAHT).
- Had the Trust VITT guidance been in place at the time, the WAHT Haematologist would have been prompted to contact their counterpart Haematologist at QEHB which may have accelerated the process of transfer; this did not happen until the day after the patient’s admission .
2. Within the course of the evidence at the inquest it was identified that, whilst there was no NICE Guidance or a local policy at WAH, there was a number of publications on the management of VITT and patients presenting with complications post Astra Zeneca Vaccination:
i. Guidance from the Expert Haematology Panel (EHP) on Covid-19 Vaccine-induced Immune Thrombocytopenia and Thrombosis (VITT) 28th May 2021
ii. Joint guidance from the Royal College of Emergency medicine, the Society for Acute Medicine and the Royal College of Physicians ‘Management of patients presenting to the Emergency Department/ Acute Medicine with symptoms 5-42 days post Astra Zeneca vaccine’ 24th May 2021
iii. 'Management of Cerebral Venous Sinus Thrombosis following COVID-19 vaccination. A neurosurgical guide.' from the British Society of Neurological Surgeons 19th April 2021
3. Evidence also identified that the University Hospitals Birmingham NHS Foundation Trust had also put in place a Regional VITT Pathway that was communicated to Haematologists and Neurologists across the region in March 2021. Prior to Jack's admission to the Alexandra Hospital on the 8ᵗʰ June 2021 4 patients had been transferred from the WAH to the QEH under the pathway including 1 patient from the Alexandra Hospital.
4. The WAH investigation did not identify the above guidance or Pathway and did not provide any explanation of why they were not followed in Jack's case.
5. Concerns were raised in the management of Jack's care whilst at the Alexandra Hospital, in particular the emergency department decision to refer to the medical and not neurology team, the level of observations whilst on ward 11 and the fact that family were reporting a concern that Jack was deteriorating during the afternoon of the 9ᵗʰ June 2021. The WAH investigation report does not record that these matters (or any other aspect of clinical care) were investigated, the conclusions reached or the basis for those conclusions.
6. This raises a concern that the investigation was not sufficient and as such has not served its purpose of safeguarding patients.
7. No adequate explanation was given in evidence to explain why the investigation was incomplete.
8. If WAH serious incident investigations are not sufficient the lessons arising will not be identified and necessary action will not be taken putting lives at risk.
” Source location Jack HURN · 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 Provide regulators with assurance about appropriate referral of future patients to tertiary services.
Verbatim wording from the response “I confirm that we have discussed the concerns raised with the Care Quality Commission and Clinical Commissioning Group (as was), in particular providing assurance about the actions taken in order that any future patients presenting at our sites are referred appropriately to tertiary services.” Source location Response from NHS Worcestershire Acute Hospital
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10 Aug 2021 Alice Beatrice Pettersson · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Lack of a designated referral pathway for children with achondroplasia View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Alice Beatrice Pettersson · 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
Alice Beatrice Pettersson died at Great Ormond Street Hospital London after suffering cord compression due to undiagnosed foramen magnum stenosis associated with achondroplasia. The report identified concerns about the absence of designated referral pathways and national guidance, and about the need for prompt specialist assessment, MRI scanning and sleep studies.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a designated referral pathway for children with achondroplasia
Wider context from the report “There is no designated referral pathway for children with achondroplasia and general paediatric clinical teams are not always aware of the associated risks or clinical scenarios which should prompt immediate referral to centres of excellence.
” Source location Alice Beatrice Pettersson · Prevention of Future Deaths report
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Concerns raised 1
Failure to expedite scanning or contact tertiary neurosurgical services after specialist input View source
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mr Frank Charles Medley · Prevention of Future Deaths report
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Report summary
Mr Frank Charles Medley presented with acute weakness in all four limbs, but an MRI scan that was considered urgent was delayed for four working days. He underwent surgery for multiple paraspinal abscesses and died on 14 July 2019. The principal concerns included delays and inadequate prioritisation of imaging, deficiencies in the Trust’s adverse incident review, and shortcomings in systems for detecting adverse outcomes and coordinating relevant departments.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to expedite scanning or contact tertiary neurosurgical services after specialist input
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services ;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Source location Mr Frank Charles Medley · 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 Operate a year-round radiology inpatient coordinator or navigator function to improve referral communication, patient flow and scan escalation.
Verbatim wording from the response “Radiology in-patient Co-ordinator/Navigator role was established in November 2019. This role has supported improved patient flow and communication between referring clinical teams and the radiology team. Cover is provided 52 weeks of the year by the Radiology Administrative function. A Standard Operating Procedure describing the functions of this role and the actions required by referrers to improve access and efficiency in radiology is being developed to support this function. Communications have been clarified to advise on the most appropriate manner for teams to access the In-patient Navigator. This is the route that teams will use to find out when a scan is planned and also to expedite imaging which has not yet been planned.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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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 Develop a standard operating procedure defining navigator functions and referrer actions for radiology access and efficiency.
Verbatim wording from the response “Radiology in-patient Co-ordinator/Navigator role was established in November 2019. This role has supported improved patient flow and communication between referring clinical teams and the radiology team. Cover is provided 52 weeks of the year by the Radiology Administrative function. A Standard Operating Procedure describing the functions of this role and the actions required by referrers to improve access and efficiency in radiology is being developed to support this function. Communications have been clarified to advise on the most appropriate manner for teams to access the In-patient Navigator. This is the route that teams will use to find out when a scan is planned and also to expedite imaging which has not yet been planned.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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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 Hold twice-weekly clinico-radiological meetings to discuss difficult cases and support imaging decisions without requiring personal attendance.
Verbatim wording from the response “Clinico-radiological meetings were established in November 2020 and now occur twice weekly on Monday and Friday on AMU. It is intended that when possible, a third meeting will be provided on a Wednesday to provide better support through the working week. This development allows a forum in which difficult cases can be discussed and advice and guidance provided on the optimum imaging technique and/or interpretation of unusual report findings and has been a significant success; building improved relationships and communication between clinical teams on AMU and the radiology directorate. This meeting explicitly addresses the human factors highlighted in this case; ensuring that patient management is equitable regardless of the staff on duty and that clinical discussions can be held without personal attendance.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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21 Oct 2019 Sharon Jamela Reeve · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Lack of clarity about information required in electronic referrals View source
This report raised 8 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
Sharon Jamela Reeve · 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
Sharon Jamela Reeve developed a persistent headache, underwent investigations and was discharged after an electronic referral to a tertiary neurosurgical unit. She was found unresponsive on 10 March 2018, underwent emergency surgery and died on 14 March 2018. The principal concerns were unclear referral pathways, incomplete and ineffective communication between hospitals, delays in specialist review, and inadequate clarity about the electronic referral system.
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 clarity about information required in electronic referrals
Wider context from the report “(3) Evidence was heard at the Inquest to the effect that numerous inappropriate referrals are made to the tertiary neurosurgical unit. I am concerned that this may be due to a lack of clarity at the entrance to the electronic portal so as to: -
(a) Make plain the circumstances in which it should be used – and where it is not appropriate.
(b) The information required to be included.
(c) The precise issues upon which guidance is sought.
If relatively junior clinicians are likely to be involved in the interface between DGH and tertiary specialist centres, there may well be a training component to improve the quality of information and requests submitted.
It was said that the electronic referral system in use at Leeds General Infirmary Neurosurgical Unit in March 2018 has been replaced. As the Inquest was not provided with details of the replacement system, the court was not able to consider whether the concerns outlined here have been resolved.
” Source location Sharon Jamela Reeve · Prevention of Future Deaths report
Open source report
22 Mar 2017 Michael Uriely · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2
Failure to refer high-risk asthma patients to tertiary respiratory services View source Failure to complete formal referral to a tertiary respiratory service View source
This report raised 23 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
Michael Uriely · 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 Uriely had asthma from early childhood, which deteriorated and was uncontrolled in the seven months before his death. The report identified missed opportunities in the management of his asthma, including a lack of coordinated overall responsibility and long-term care planning, failure to assess and optimise treatment consistently, poor communication between services, and failure to refer him to a specialist respiratory service.
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 refer high-risk asthma patients to tertiary respiratory services
Wider context from the report “7) Two further areas of concern presented, inter related but independently significant and critical in this matter:
A) Michael’s mother readily presented her child for care in and out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the failure to refer this child to a tertiary respiratory service which may have resulted in a different approach to his treatment which may have prevented his death, by:
i) The general practitioners who failed to recognise the severity of his condition and that referral to a tertiary unit could have been considered.
ii) The A&E and inpatient service at the local hospital.
” Source location Michael Uriely · Prevention of Future Deaths report
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 Failure to complete formal referral to a tertiary respiratory service
Wider context from the report “8) Michael was never formally referred to a tertiary respiratory service .
” Source location Michael Uriely · Prevention of Future Deaths report
Open source report
Concerns raised 2
Failure to enable appropriate referrals to the tertiary paediatric service View source Failure to refer paediatric asthma patients to tertiary respiratory specialists View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Tamara Mills · 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
Tamara Mills, who had longstanding asthma and repeated acute exacerbations, developed breathing difficulties during the night of 10th/11th April 2015 and died after paramedics were called. The principal concerns were fragmented care, inadequate coordination and communication, insufficient recognition of her deteriorating chronic respiratory condition, and the absence of a long-term management plan.
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 enable appropriate referrals to the tertiary paediatric service
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust . The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service.
” Source location Tamara Mills · Prevention of Future Deaths report
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 Failure to refer paediatric asthma patients to tertiary respiratory specialists
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service .
” Source location Tamara Mills · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to refer high-risk patients to a Tertiary Centre for second opinion and management 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
Betty SMITH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Betty SMITH underwent surgery for a large intrathoracic hiatus hernia on 22 October 2012, deteriorated the following day, was admitted to intensive care on 24 October, and died on 25 October from intraabdominal and intrathoracic haemorrhage following repair of the hiatus hernia. Concerns included the lack of a secured High Dependency Unit bed before surgery, inadequate anaesthetic pre-assessment and the failure to refer her to a tertiary centre. The report also identified reduced intensive care capacity due to closed beds and nursing shortages as compromising care.
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 refer high-risk patients to a Tertiary Centre for second opinion and management
Wider context from the report “• To return Betty SMITH to a ward post-operatively and not secure an High Dependency Unit bed before surgery commenced falls well below accepted care. The expert opinion was concerned that such a high risk patient should have been referred to a Tertiary Centre for a second opinion and probably management .
” Source location Betty SMITH · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.