8 Jun 2026 Barbara Joan COPE · Prevention of Future Deaths report South Yorkshire (West)
View report summary
Concerns raised 2
Delays in following up requested blood tests View source Failure to communicate and follow up abnormal blood results View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Rotherham 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. 8
the Rotherham NHS Foundation Trust
Flag all abnormal results within MEDITECH.
View source
the Rotherham NHS Foundation Trust
Introduce and communicate a Trust-wide standard operating procedure for managing investigation results.
View source
the Rotherham NHS Foundation Trust
Review and update the standard operating procedure for critically abnormal pathology results in clinical areas.
View source
the Rotherham NHS Foundation Trust
Conduct a Pathology audit of documentation for time-critical results telephoned to clinical areas.
View source
the Rotherham NHS Foundation Trust
Conduct an additional 50-result audit of documentation and appropriate action for time-critical results.
View source
the Rotherham NHS Foundation Trust
Develop a Power BI module to monitor acknowledgement of results.
View source
the Rotherham NHS Foundation Trust
Launch an Urgent and Emergency Care Centre pilot using the alertive bleep system to flag critical blood results.
View source
the Rotherham NHS Foundation Trust
Include learning from the incident in the Quality Newsletter, focusing on acting upon time-critical blood results.
View source See 5 more actions
×
AI-generated summary
Barbara Joan COPE · 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
Barbara Joan COPE, a 75-year-old woman, presented to Rotherham Hospital with decreased conscious levels, slurred speech and reduced oral intake, and was later found to have a high paracetamol level. The result was not reviewed or acted upon for approximately 19 hours, delaying time-critical treatment. The principal concerns were failures in communicating and following up abnormal results, reviewing investigations during clinical deterioration, and clearly assigning responsibility for ongoing 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 Delays in following up requested blood tests
Wider context from the report “(3) This patient was transferred from the emergency department to the care of Surgery. A referral was then made for Gastroenterology input, they then requested a blood test for paracetamol levels. This was not followed up for 17 hours . There needs to be clear communication, understanding and record keeping of who is responsible for patient and the ongoing follow up and care in these circumstances.
” Source location Barbara Joan COPE · 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 communicate and follow up abnormal blood results
Wider context from the report “(1) Although a blood sample was collected and tested in a timely manner, there was no evidence of communication and/or follow up of the abnormal result , therefore time critical medication was not commenced until 19 hours later.
” Source location Barbara Joan COPE · Prevention of Future Deaths report
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 Flag all abnormal results within MEDITECH.
Verbatim wording from the response “Over the years, the Trust has undertaken a programme of quality improvement work, led by the Deputy Medical Director and Chief Clinical Information Officer to strengthen our responsiveness to abnormal results. This has included ensuring that all abnormal results are flagged within MEDITECH (our electronic patient record). In addition, a Standard Operating Procedure setting out the required actions for managing investigation results was introduced and communicated Trust wide.” Source location Response from Rotherham District General Hospitals
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 Introduce and communicate a Trust-wide standard operating procedure for managing investigation results.
Verbatim wording from the response “Over the years, the Trust has undertaken a programme of quality improvement work, led by the Deputy Medical Director and Chief Clinical Information Officer to strengthen our responsiveness to abnormal results. This has included ensuring that all abnormal results are flagged within MEDITECH (our electronic patient record). In addition, a Standard Operating Procedure setting out the required actions for managing investigation results was introduced and communicated Trust wide.” Source location Response from Rotherham District General Hospitals
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 and update the standard operating procedure for critically abnormal pathology results in clinical areas.
Verbatim wording from the response “Since Mrs Cope’s death we have reviewed and updated the Standard Operating Procedure for the Management of Critically Abnormal Pathology Results in Clinical Areas and I attach a copy of the same for your reference.” Source location Response from Rotherham District General Hospitals
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 Conduct a Pathology audit of documentation for time-critical results telephoned to clinical areas.
Verbatim wording from the response “An audit has been conducted by Pathology to check that the documentation for time critical results telephoned to clinical areas complies with the Standard Operating Procedure with a finding that results audited had been communicated in a timely manner. An additional audit of 50 results is currently underway focusing on whether time critical results have been documented and acted on appropriately. The result of this audit is expected by the end of August 2026.” Source location Response from Rotherham District General Hospitals
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 Conduct an additional 50-result audit of documentation and appropriate action for time-critical results.
Verbatim wording from the response “An audit has been conducted by Pathology to check that the documentation for time critical results telephoned to clinical areas complies with the Standard Operating Procedure with a finding that results audited had been communicated in a timely manner. An additional audit of 50 results is currently underway focusing on whether time critical results have been documented and acted on appropriately. The result of this audit is expected by the end of August 2026.” Source location Response from Rotherham District General Hospitals
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 a Power BI module to monitor acknowledgement of results.
Verbatim wording from the response “In addition, the Trust has developed a Power BI module to monitor acknowledgement of results which continues to show an improvement in clinicians’ responsiveness to the management of test results.” Source location Response from Rotherham District General Hospitals
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 Launch an Urgent and Emergency Care Centre pilot using the alertive bleep system to flag critical blood results.
Verbatim wording from the response “I was concerned to hear that Mrs Cope deteriorated overnight, requiring two separate clinical reviews and despite this, her blood results were not reviewed. The Trust has a clear handover process in place whereby medical staff working in hours, handover tasks for follow up to the out of hours team at the face-to-face handover meetings. In addition to this, we will imminently launch a pilot within our Urgent and Emergency Care Centre of the use of the ‘alertive bleep’ system which flags critical blood results on the bleep system.” Source location Response from Rotherham District General Hospitals
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 Include learning from the incident in the Quality Newsletter, focusing on acting upon time-critical blood results.
Verbatim wording from the response “The Deputy Chief Nurse in conjunction with colleagues from the learning from deaths programme, clinical effectiveness team and the quality governance team will include the learning from this incident in the Quality Newsletter focusing on the importance of acting upon time critical blood results.” Source location Response from Rotherham District General Hospitals
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 Existing face-to-face handover arrangements require follow-up tasks to be transferred to the out-of-hours team.
Verbatim wording from the response “I was concerned to hear that Mrs Cope deteriorated overnight, requiring two separate clinical reviews and despite this, her blood results were not reviewed. The Trust has a clear handover process in place whereby medical staff working in hours, handover tasks for follow up to the out of hours team at the face-to-face handover meetings. In addition to this, we will imminently launch a pilot within our Urgent and Emergency Care Centre of the use of the ‘alertive bleep’ system which flags critical blood results on the bleep system.” Source location Response from Rotherham District General Hospitals
Open published response
6 Feb 2026 Mr Stephen Martin Rhodes · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2
Failure to adequately scrutinise laboratory blood test results View source Failure to prominently flag abnormal laboratory results View source
Linked responses
NHS England Quarry Bank Medical Centre
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
NHS England
Pilot safe transmission and ingestion of DAPB4101 pathology reports between laboratories and GP practices.
View source
NHS England
Publish guidance and resources supporting safe clinical messaging, test-result handling, clinical decision support and digital clinical safety.
View source
Quarry Bank Medical Centre
Notify the laboratory of missing NT-proBNP alerts and request corrected reporting.
View source
Quarry Bank Medical Centre
Implement the MY Bot AI triage system to segregate results and alert the duty doctor to urgent abnormal findings.
View source
Quarry Bank Medical Centre
Reissue the Results Management SOP, retaining requesting-clinician responsibility and escalating results unfiled beyond 24 hours.
View source
Quarry Bank Medical Centre
Introduce mandatory same-day review and documented action for NT-proBNP values exceeding 400.
View source
Quarry Bank Medical Centre
Introduce an EMIS Web abnormal-alert framework for critical biomarkers and require documented acknowledgment or reasons for not following referral recommendations.
View source
Quarry Bank Medical Centre
Introduce cross-filing tasks and secondary review safeguards for results filed by another clinician and specified critical cardiac biomarkers.
View source
Quarry Bank Medical Centre
Develop and operate a clinical audit programme for significant results and referral completion, including fortnightly, monthly-governance, and quarterly NT-proBNP audits.
View source
Quarry Bank Medical Centre
Monitor revised-protocol compliance through monthly clinical governance meetings and formally review change effectiveness at three and six months.
View source
NHS England
Promote wider standardisation of pathology result-flagging conventions.
View source See 8 more actions
×
AI-generated summary
Mr Stephen Martin Rhodes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Stephen Martin Rhodes, who had progressive shortness of breath, had a markedly raised NT-proBNP result that was filed in the mistaken belief that there was no abnormal finding. He collapsed and died after developing a cardiac arrest while working as a delivery driver on 11 March 2025. The principal concern was that the blood test result was not adequately scrutinised and the recommended specialist referral and echocardiography within two weeks did not occur; the inquest conclusion was narrative, with natural causes contributed to by neglect.
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 adequately scrutinise laboratory blood test results
Wider context from the report “2. My concern is that the blood test results from the laboratory were not adequately scrutinised by the GP . The blood test results reported on the 17 September 2024 showed normal renal function, normal liver function and bone metabolism. However, the NT-Brain Natriuretic Peptide results which are a marker of increased left atrial pressure and screen for heart failure was markedly raised at 3473 (normal expected for this age group < 400). This was reported to the practice and noted in the practice record with the advice from the laboratory to “refer for specialist assessment and transthoracic echocardiography within 2 weeks”.
3. The GP giving evidence, described that the Practice could have up to several hundred reports a day. They could not adequately explain how the error occurred. However, one suggestion was that the abnormal results were not found on the top page of the report or highlighted in red.
4. I also heard, evidence that since this incident the laboratory involved has now updated their reporting to ensure that abnormal results are flagged on the first page of the report.
” Source location Mr Stephen Martin Rhodes · 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 prominently flag abnormal laboratory results
Wider context from the report “2. My concern is that the blood test results from the laboratory were not adequately scrutinised by the GP. The blood test results reported on the 17 September 2024 showed normal renal function, normal liver function and bone metabolism. However, the NT-Brain Natriuretic Peptide results which are a marker of increased left atrial pressure and screen for heart failure was markedly raised at 3473 (normal expected for this age group < 400). This was reported to the practice and noted in the practice record with the advice from the laboratory to “refer for specialist assessment and transthoracic echocardiography within 2 weeks”.
3. The GP giving evidence, described that the Practice could have up to several hundred reports a day. They could not adequately explain how the error occurred. However, one suggestion was that the abnormal results were not found on the top page of the report or highlighted in red .
4. I also heard, evidence that since this incident the laboratory involved has now updated their reporting to ensure that abnormal results are flagged on the first page of the report.
” Source location Mr Stephen Martin Rhodes · Prevention of Future Deaths report
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 Pilot safe transmission and ingestion of DAPB4101 pathology reports between laboratories and GP practices.
Verbatim wording from the response “A pilot is underway to establish and prove how a DAPB4101 pathology report can be sent from labs and ingested by GP practices safely. This will involve working with the GP system supplier, and the three pathology middleware suppliers that enable national coverage for lab to GP reporting as well as with Berkshire & Surrey NHS Pathology Services. Once the pilot has completed, implementing DAPB4101 will then go onto NHS England's GP system suppliers’ managed roadmap of development work, leading to national roll-out.” Source location 2026-0083 - Response from NHS England
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 Publish guidance and resources supporting safe clinical messaging, test-result handling, clinical decision support and digital clinical safety.
Verbatim wording from the response “While operational arrangements are managed at individual practice level, NHS England has published several resources available to support safe systems of work, including:” Source location 2026-0083 - Response from NHS England
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 Notify the laboratory of missing NT-proBNP alerts and request corrected reporting.
Verbatim wording from the response “1. Laboratory Reporting (actioned 14 March 2025): On 14 March 2025, the Practice wrote to Russells Hall Hospital laboratory to notify them that their reports were not including an alert on raised NT-proBNP results. The laboratory conducted a review and their reports now include an alert when NT-proBNP results are raised. As these results now carry a laboratory red flag indicator, they are correctly identified during the Practice’s manual filtering process and routed into the action-required category for clinical review. The laboratory has also updated its report format so that all abnormal results are flagged on the first page of each report. This change will benefit all practices receiving reports from this laboratory and materially reduces the risk of a similar event occurring across the wider system.” Source location 2026-0083 - Response from Quarry Bank Medical Centre
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 the MY Bot AI triage system to segregate results and alert the duty doctor to urgent abnormal findings.
Verbatim wording from the response “2. MY Bot AI Triage System (implemented 18 February 2026): The Practice introduced the MY bot AI triage system on 18 February 2026 following a careful, phased assessment to ensure clinical accuracy and safety prior to full adoption. MY bot works by applying an intelligent filter to incoming blood test results, segregating them into two categories: results that require clinical action and results that do not require action. This enables each GP to focus their review directly on results requiring” Source location 2026-0083 - Response from Quarry Bank Medical Centre
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 Reissue the Results Management SOP, retaining requesting-clinician responsibility and escalating results unfiled beyond 24 hours.
Verbatim wording from the response “3. Revised Results Management SOP (18 February 2026): The Results Management Policy has been formally reviewed and reissued. The updated SOP explicitly mandates that the requesting clinician retains responsibility for the review, interpretation, actioning, and filing of all investigation results within 24 hours of availability. An automated alert is generated where results remain unfiled beyond this defined timeframe, with escalation to the clinical lead where defined backlog thresholds are exceeded.” Source location 2026-0083 - Response from Quarry Bank Medical Centre
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 Introduce mandatory same-day review and documented action for NT-proBNP values exceeding 400.
Verbatim wording from the response “4. Mandatory Same-Day Protocol for Raised NT-proBNP (18 February 2026): A mandatory same-day clinical review and documented action protocol has been introduced for all NT-proBNP values exceeding 400 – the threshold above which results are considered abnormal. The Practice has deliberately adopted this more conservative threshold rather than the NICE urgent referral threshold of >2000, to ensure that any raised NT-proBNP result, however early in its trajectory, receives prompt clinical attention on the day of receipt without exception.” Source location 2026-0083 - Response from Quarry Bank Medical Centre
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 Introduce an EMIS Web abnormal-alert framework for critical biomarkers and require documented acknowledgment or reasons for not following referral recommendations.
Verbatim wording from the response “5. High-Risk Biomarker Escalation Framework and Abnormal Alert System (18 February 2026): The “Abnormal Alert” system has been introduced within EMIS Web as an additional safety check. A defined list of critical biomarkers – including NT-proBNP, markedly abnormal potassium, CRP, and PSA – has been agreed, with results exceeding defined thresholds flagged for enhanced scrutiny. No result carrying a laboratory recommendation for onward referral may now be filed without documented clinician acknowledgment. Where a referral recommendation is not followed, a documented clinical reason must be recorded.” Source location 2026-0083 - Response from Quarry Bank Medical Centre
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 Introduce cross-filing tasks and secondary review safeguards for results filed by another clinician and specified critical cardiac biomarkers.
Verbatim wording from the response “6. Cross-Filing Safeguard and Secondary Review (18 February 2026): Where results are reviewed and filed by a clinician other than the requesting GP, that clinician must send the requesting GP a task to review the results upon their return, ensuring a secondary review by the clinician with full knowledge of the clinical context. A secondary review safeguard has additionally been introduced for specified critical cardiac biomarkers to provide additional oversight where results exceed urgent referral criteria.” Source location 2026-0083 - Response from Quarry Bank Medical Centre
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 operate a clinical audit programme for significant results and referral completion, including fortnightly, monthly-governance, and quarterly NT-proBNP audits.
Verbatim wording from the response “8. Clinical Audit Programme (18 February 2026): The Practice has developed a programme of practice-level clinical audits targeting results of high clinical significance, designed to provide ongoing assurance that abnormal results are identified, actioned, and that time-bound referral recommendations are completed within the specified timeframe. The audit programme includes NT-proBNP and BNP,” Source location 2026-0083 - Response from Quarry Bank Medical Centre
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 Monitor revised-protocol compliance through monthly clinical governance meetings and formally review change effectiveness at three and six months.
Verbatim wording from the response “PSA, and other clinically significant markers, to be expanded through ongoing clinical governance review. Audits are conducted on a fortnightly basis with outcomes reported to the monthly clinical governance meeting, at which results management is now a standing agenda item. A quarterly audit of NT-proBNP results and associated referral pathways will be conducted for a 12-month period to provide sustained assurance of compliance. The initial audit has confirmed that no other raised results have been missed.” Source location 2026-0083 - Response from Quarry Bank Medical Centre
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 Promote wider standardisation of pathology result-flagging conventions.
Verbatim wording from the response “The Pathology Transformation and Interoperability Programme in NHS England is currently undertaking the opportunity to promote:” Source location 2026-0083 - Response from NHS England
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 Individual GP practices manage operational arrangements for reviewing, assigning and acting on pathology results.
Verbatim wording from the response “NHS England recognises the need for robust result review processes are needed at pace in busy practices and the ability to correctly assign and act on results.” Source location 2026-0083 - Response from NHS England
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 Laboratory and GP system suppliers are primarily responsible for pathology result formatting, structure, presentation and display of abnormal results.
Verbatim wording from the response “The responsibility for the formatting, structure and presentation of pathology results sits primarily with:” Source location 2026-0083 - Response from NHS England
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 NHS England may review national laboratory guidance on abnormal-result flagging and standardise laboratory alert protocols.
Verbatim wording from the response “The Practice notes that a copy of the Regulation 28 Report has been sent to NHS England and fully supports the Coroner’s suggestion that NHS England may wish to review national guidance for laboratories regarding the flagging of abnormal results. The Practice’s direct experience in this case demonstrates that a laboratory’s failure to flag an abnormal result at source can silently circumvent even well-designed electronic filtering systems at practice level. National standardisation of laboratory alert protocols would represent a meaningful and systemic patient safety improvement. The Practice would welcome any such guidance.” Source location 2026-0083 - Response from Quarry Bank Medical Centre
Open published response
Concerns raised 1
Failure to carry out regular blood tests View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Premiere Health Limited
Enforce the hospital discharge and clinical follow-up procedure, including review, action logging, GP confirmation and management audit.
View source
×
AI-generated summary
Pamela George · 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
Pamela George, aged 70, died at Derriford Hospital on 30 June 2023 after being urgently admitted with suspected sepsis. The report identified missed opportunities to carry out required blood tests, manage a breast infection, document and escalate a fall and medical concerns, assess and record capacity, and maintain relevant care-home policies and records.
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 carry out regular blood tests
Wider context from the report “1. Cann House missed an opportunity to carry out regular blood tests on Miss George between 23rd May and 29th June. These blood tests may have identified the need to continue to treat acute kidney injury which if left untreated may have affected her resilience to infection. The system for ensuring that discharge summaries are actioned was not available for me to see and I was not clear if any policy on this issue existed.
” Source location Pamela George · Prevention of Future Deaths report
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 Enforce the hospital discharge and clinical follow-up procedure, including review, action logging, GP confirmation and management audit.
Verbatim wording from the response “• The organisation has enforced its formal Hospital Discharge and Clinical Follow-Up Procedure, which includes:” Source location Response from Cann House
Open published response
23 Apr 2025 Lorraine Sandra Parker · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1
Lack of guidance requiring consideration of CT scanning when CRP is high and not decreasing or rising after major abdominal surgery View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Lorraine Sandra Parker · 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
Lorraine Parker underwent surgery for sigmoid colon cancer in January 2024 and was discharged with a rising CRP and no post-operative scan. After returning to hospital, an anastomotic leak was initially missed, and she later died at Royal Berkshire Hospital on 30 March 2024 following a sudden deterioration. The principal concerns were the lack of guidance requiring consideration of CT scanning when CRP is high and rising or not decreasing, and reliance on clinical judgement without sufficiently accounting for objective blood-test results.
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 guidance requiring consideration of CT scanning when CRP is high and not decreasing or rising after major abdominal surgery
Wider context from the report “2. There is currently no guidance which requires surgeons to consider scanning for patients who have undergone major abdominal surgery and whose CRP is high and not decreasing , as was the case here at the time Lorraine was discharged from hospital on 31st January 2024.
3. There may be some difficulty in creating a hard line requirement for CT scanning based on a particular CRP result, but I am concerned that there is no guidance in place for requiring a consultant to consider this – perhaps when the CRP is above a certain figure and either not decreasing or continuing to rise . Any such guidance could still allow for clinical judgement – and documenting of the reasons for that decision.
4. It is my experience that clinical judgement alone, particularly where a patient looks well “from the end of the bed” is not always sufficient in this scenario. I have seen a number of avoidable death cases in this context. The purpose of blood test results is to flag up objective areas of concern. There is much reference to chasing up CRP results in Lorraine’s records, but these do not appear to have been taken into account at the time that she was discharged from the hospital without a post-operative scan.
” Source location Lorraine Sandra Parker · Prevention of Future Deaths report
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 Provide existing guidance on postoperative CRP monitoring and CT investigation triggers.
Verbatim wording from the response “In relation to the matters of concern raised, I attach Issues in Professional Practice Guidance on the Prevention, Diagnosis and Management of Colorectal Anastomotic Leak, produced in collaboration with ACPGBI. Although published in 2016, the guidance around post-operative CRP monitoring and triggering subsequent radiological investigation remains as pertinent to clinical practice now as it was then. Please see in particular pages 16-17, where cut off values for CRP triggering a subsequent CT scan are also considered. In addition, there have been several subsequent publications (available on Pubmed) confirming this practice.” Source location Response from The Association of Coloproctology of Great Britain and Ireland
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 Contact ACPGBI to support its assessment of guidance needs and dissemination of any resulting guidance or communications.
Verbatim wording from the response “Deterioration of the surgical patient following bowel surgery, and appropriate perioperative care, is covered in the postgraduate training surgical curriculum in the Intercollegiate Surgical Curriculum Programme (often referred to as ‘ISCP’). We note that the Association of Coloproctology of Great Britain and Ireland (ACPGBI) has been informed of the report and they are best placed to consider the need for guidance. We will contact them to support their assessment and any dissemination of guidance or other communications.” Source location Response from Royal College of Surgeons
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 Share the case details with NICE’s prioritisation team for consideration of whether further action is needed.
Verbatim wording from the response “The NICE guideline does not provide detailed protocols for postoperative tests or scans, and clinicians would be expected to use their judgement and follow local protocols or other relevant professional guidance. However, whilst the Department has no immediate plans to instruct NICE to produce standalone guidance on post-surgery imaging based on CRP thresholds, details of this case have been shared with colleagues in NICE’s prioritisation team to consider if further action should be taken.” Source location Response from DHSC
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 Existing guidance on CRP monitoring and CT investigation makes further ACPGBI guidance unnecessary at this time.
Verbatim wording from the response “In relation to the matters of concern raised, I attach Issues in Professional Practice Guidance on the Prevention, Diagnosis and Management of Colorectal Anastomotic Leak, produced in collaboration with ACPGBI. Although published in 2016, the guidance around post-operative CRP monitoring and triggering subsequent radiological investigation remains as pertinent to clinical practice now as it was then. Please see in particular pages 16-17, where cut off values for CRP triggering a subsequent CT scan are also considered. In addition, there have been several subsequent publications (available on Pubmed) confirming this practice.” Source location Response from The Association of Coloproctology of Great Britain and Ireland
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 ACPGBI is best placed to consider whether guidance is needed on recognising deterioration after bowel surgery.
Verbatim wording from the response “Deterioration of the surgical patient following bowel surgery, and appropriate perioperative care, is covered in the postgraduate training surgical curriculum in the Intercollegiate Surgical Curriculum Programme (often referred to as ‘ISCP’). We note that the Association of Coloproctology of Great Britain and Ireland (ACPGBI) has been informed of the report and they are best placed to consider the need for guidance. We will contact them to support their assessment and any dissemination of guidance or other communications.” Source location Response from Royal College of Surgeons
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 Clinical guidance is primarily the responsibility of NICE and relevant Royal Colleges, while Trusts should implement appropriate local processes or guidance.
Verbatim wording from the response “While NHS England notes your concerns, clinical guidelines are primarily the responsibility of the National Institute for Health and Care Excellence (NICE) and the appropriate Royal Colleges. NHS Trusts are expected to have due regard to any clinical guidelines and to implement the appropriate local processes and/or guidance. I note that you have also addressed your Report to the Association of Coloproctology of Great Britain (ACPGBI) and the Royal College of Surgeons, who are the more appropriate organisations to respond to your concerns.” Source location Response from NHS England
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 Further guidance on CT scanning after abdominal surgery with raised CRP is not required because existing guidance and evidence address anastomotic leaks.
Verbatim wording from the response “NHS England has however discussed your Report with the ACPGBI, and it is agreed that there is not a requirement for further guidance to be written. CRP levels are” Source location Response from NHS England
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 Existing NICE guidance, clinical judgement, local protocols and relevant professional guidance are relied upon instead of standalone CRP-based postoperative imaging guidance.
Verbatim wording from the response “With regard to concerns about guidance for clinicians, the NICE guideline on colorectal cancer (NG151) aims to improve quality of life and survival for adults with colorectal cancer by providing evidence-based recommendations on the management of both local disease and metastatic (secondary) cancer. It covers which interventions should be used for different types and stages of the disease, helping to guide decisions on surgery, chemotherapy, and other treatments.” Source location Response from DHSC
Open published response
5 Jun 2024 Bernard Compton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to ensure urgent blood results are acted upon immediately View source
This report raised 5 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.
×
AI-generated summary
Bernard Compton · 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
Bernard Compton developed symptoms of a myocardial infarction, but delays in ambulance response, ECG interpretation, triage, blood-result review and clinical assessment meant that the optimum window for intervention had passed. He later suffered a left ventricular rupture and died on 19 October 2023. The concerns included inadequate oversight of patients and urgent results, unclear systems for repeating and acting on tests, and demand-related delays in ambulance and emergency 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 ensure urgent blood results are acted upon immediately
Wider context from the report “It was unclear what system was in place to effectively ensure urgent blood results were acted upon immediately . The inquest was told the lab would telephone through on some occasions. It was unclear what the protocol was and who had oversight of it .
” Source location Bernard Compton · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to complete or communicate required repeat blood tests 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.
×
AI-generated summary
Philip Hawkins · 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
Philip Hawkins, aged 97, suffered a fall at home on 18 March 2023, was transferred by ambulance to hospital, and died on 23 March 2023. Concerns included delays in being admitted and allocated a bed, insufficient staffing, inability to provide care, gaps in nursing documentation, and failures in aspects of assessment and treatment.
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 complete or communicate required repeat blood tests
Wider context from the report “Care Concerns in the ED
4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas.
5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians .
6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician.
7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23.
8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him.
” Source location Philip Hawkins · Prevention of Future Deaths report
Open source report
6 Jul 2023 Elizabeth Oluwatofunmi AGBEJIMI · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 1
Failure to investigate a significantly abnormal respiratory acidosis blood gas result View source
×
AI-generated summary
Elizabeth Oluwatofunmi AGBEJIMI · 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
Elizabeth Oluwatofunmi AGBEJIMI died on 27 June 2021 at Lincoln County Hospital following multiple falls identified by the pathologist as a direct cause of death. Concerns were raised that a venous blood gas sample showing significant respiratory abnormal acidosis was not further investigated, with the deceased dying two weeks later of a respiratory condition; the report questioned whether this involved training or communication.
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 investigate a significantly abnormal respiratory acidosis blood gas result
Wider context from the report “████████ gave evidence that following a venous blood gas sample undertaken on 12th June 2021 which showed a significant respiratory abnormal acidosis reading but no further investigation was undertaken . The deceased died 2 weeks later of a respiratory condition. Is this a training/communication issue?
” Source location Elizabeth Oluwatofunmi AGBEJIMI · Prevention of Future Deaths report
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 Require ED clinicians acknowledging blood gas results to document abnormalities requiring management and the planned further management.
Verbatim wording from the response “1. Ensure better documentation of the identification of the abnormalities on the blood gas results” Source location Response from United Lincolnshire Hospitals NHS Trust
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 Have clinical audit teams in both ULHT departments audit blood gas results and documentation to assess whether the learning and actions are embedded.
Verbatim wording from the response “In order to assure that these processes have been embedded, the clinical audit team in both ULHT departments will undertake an audit of blood gas results and the documentation in them to review the learning and actions have been embedded.” Source location Response from United Lincolnshire Hospitals NHS Trust
Open published response
28 Jun 2023 Hilary THOMAS · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Delays in reviewing available blood test results View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Hilary THOMAS · 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
Hilary THOMAS attended hospital with abdominal pain on 28 and 29 October 2022, then reattended on 30 October in a shocked and profoundly unwell state. She underwent emergency surgery for ischaemic bowel caused by adhesions but died on 31 October 2022. The principal concerns were delayed review of blood test results, failure to escalate her case for consultant review, and delay in arranging a CT scan.
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 Delays in reviewing available blood test results
Wider context from the report “1. Witnesses explained at the inquest that the volume of patients attending hospital is at a level the like of which has never been seen and current resources are unable to deal with that volume. This had a direct impact on Mrs Thomas's death as the doctor treating her was unable to review her blood tests results until the evening handover, 6 and a half hours after the results were available by which time Mrs Thomas had left the department.
” Source location Hilary THOMAS · Prevention of Future Deaths report
Open source report
23 Mar 2023 Jade Paula REVELL · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1
Failure of the laboratory-results display to show all results in minimised mode View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Jade Paula REVELL · 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
Jade Revell died from a sudden cardiac event after being taken to hospital on 25 December 2021, having suffered the event at home. A low potassium result from 27 October 2021 was not communicated to her, resulting in a missed opportunity to treat hypokalaemia and monitor potassium levels. The report raises concerns that the GP computer system may not display all blood results clearly, increasing the risk that abnormal results are missed and not acted upon.
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 of the laboratory-results display to show all results in minimised mode
Wider context from the report “The SystemOne computer programme used by the GP Practice can, when a clinician is reviewing the results (blood) from the laboratory with the screen in minimised mode (which is not unusual because of a need to work with a split screen), not show all the results . To do so would need the clinician to scroll down and a scroll feature is not available . This gives rise to the risk of an abnormal result being missed and unactioned.
Abnormal (out of range) should be more visible – appear at the top of a list and colour coded to minimise the risk of a result not being seen / missed. The computer programme prevents this.
” Source location Jade Paula REVELL · Prevention of Future Deaths report
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 Reset the results-view scroll bar to the top when selecting another result and release the change to all users.
Verbatim wording from the response “As a result of our conversation we were able to identify a change to be made in the system and this was released to all our users on the evening of 13th October 2022.” Source location Response from TPP
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 The system displays scrollbars when information cannot fit on screen, and the table layout used to review results has no issue.
Verbatim wording from the response “Figure 3 shows the table layout for reviewing results – where abnormal results are highlighted. There is no issue with this screen.” Source location Response from TPP
Open published response
11 Aug 2022 Ms Katie Horne · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1
Delays in review and follow-up of crucial blood test results View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Ms Katie Horne · 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
Ms Katie Horne presented with jaundice, developed severe hepatitis and liver failure, tested positive for Covid-19, developed Covid pneumonitis, and died on 11 April 2020. The principal concerns were delays in identifying crucial blood test results, consulting a gastroenterologist, starting steroid therapy, and referring her for possible liver transplantation.
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 Delays in review and follow-up of crucial blood test results
Wider context from the report “Despite multiple attendances as an outpatient with deteriorating hepatitis, it took 15 days for crucial blood test results to be seen by the doctors (in part due to lab backlog but there was no evidence of any doctor prioritising or chasing the results ) or for a gastroenterologist to be consulted on care. This led to a liver biopsy not being possible (in part as her blood clotting had deteriorated) and later than necessary commencement of steroid therapy and consequent later referral for liver transplantation at Kings College Hospital.
” Source location Ms Katie Horne · Prevention of Future Deaths report
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 a virtual environment for tracking outstanding patient investigations, including blood test results.
Verbatim wording from the response “2. We now have a virtual environment which allows for the tracking of outstanding patient investigations, including blood test results.” Source location Response from University Hospitals Sussex
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 Gastroenterology hot clinic to ensure jaundice patients are referred after initial assessment and ultrasound, with Registrar and Consultant support.
Verbatim wording from the response “3. We have established a Gastroenterology ‘hot clinic’ (urgent new presentation clinic), which ensures referral of all jaundice patients after their initial assessment and ultrasound scan. This ‘hot clinic’ is run by the Gastroenterology Registrars with Consultant support.” Source location Response from University Hospitals Sussex
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.