Concerns raised 1
Failure to follow up abnormal blood test results View source
This report raised 15 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
Norman Arthur BEARD · 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
Norman Arthur BEARD suffered a fall, was admitted to hospital, and later transferred to Daisy Bank Nursing Home, where he developed serious pressure sores, dehydration and significant weight loss. He died at Abbey Court Nursing Home on 14 February 2015. Concerns included delayed referral and inadequate treatment of pressure sores, shortages of staff and essential supplies, incomplete care records, inadequate response to weight loss and minimal GP involvement.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to follow up abnormal blood test results
Wider context from the report “(7) The involvement of the GP was minimal and there was no follow up when blood tests revealed an abnormality .
” Source location Norman Arthur BEARD · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to undertake requested liver function tests when clinically required View source
This report raised 2 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
Hywel Dda University LHB
Remind medical staff to undertake clinically justified tests and discuss provider-declined investigations with the ordering consultant.
View source
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AI-generated summary
Cerith Wyn Pugh · 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
Cerith Wyn Pugh underwent surgery for bowel obstruction in March 2013, experienced a cardiac arrest and further surgery, and had subsequent hospital readmissions. He died on 20 May 2014 after developing bleeding from his ileostomy; the inquest recorded multi-organ failure, ischaemic bowel disease, and cholelithiasis with mechanical jaundice. Concerns included consultant referrals being handled initially by middle grade doctors and liver function tests being declined because testing had been conducted less than three days earlier, without evidence of a mechanism to override that guidance when clinically appropriate.
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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 undertake requested liver function tests when clinically required
Wider context from the report “That liver function tests were requested but the Health Board declined to undertake these for reasons of demand management on the basis that had been done some three days earlier . Expert evidence received at the inquest was highly critical of this practice. Whilst 72 hour testing is in accordance with guidance contained in guidance from the Association for Clinical Biochemistry and the Royal College of Pathologists both documents are clear that the guidance must be capable of being overridden if clinically appropriate. There was no evidence of any mechanism to override the guidance or, if such guidance existed, that it was known to staff.
” Source location Cerith Wyn Pugh · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind medical staff to undertake clinically justified tests and discuss provider-declined investigations with the ordering consultant.
Verbatim wording from the response “We have also reminded medical staff that where test requests are made on clinically justifiable grounds these should be undertaken regardless of guidance regarding repeating tests and in the event of an investigation being declined by a provider the matter must be discussed with the Consultant whose team has ordered the request.” Source location 2016-0271-Response-by-University-health-Board
Open published response
30 Oct 2015 Mary Catherine Bloom · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to obtain baseline bloods and subsequent APTT monitoring for heparin administration 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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AI-generated summary
Mary Catherine Bloom · 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
Mary Catherine Bloom, who had dementia and reduced oral intake, was admitted with probable left-leg ischaemia and died in hospital on 4 February 2014. Concerns included failures to record her weight, consult haematology, obtain baseline and follow-up blood tests, and make the heparin administration guidance sufficiently visible. There was also no discussion with her next of kin before a DNAR order was placed.
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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 obtain baseline bloods and subsequent APTT monitoring for heparin administration
Wider context from the report “1. There was a failure to comply with the Trust’s policy relating to the administration of heparin, by failing to weigh Mrs Bloom prior to the commencing the infusion of heparin.
2. There was a failure to consult a haematologist before the infusion of heparin in view of Mrs Blooms’ very low weight of 30 kilograms. Again, this is required by the Trust policy.
3. It was not possible to take baseline bloods before the commencement of heparin, however, attempts should have been made to retake bloods after hydration had commenced. The Trust policy requires baseline bloods to be taken and for the APTT to be checked after 6 hours.
” Source location Mary Catherine Bloom · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce an unfractionated-heparin chart and weight-based guideline with six-hour APTT checks and consultant escalation for abnormal results at extreme weights.
Verbatim wording from the response “In your letter you acknowledge receipt of three new policies that have been put in place by the Trust following the inquest and the new chart that has been introduced for the administration of unfractionated heparin. You have however raised further concerns with regards to the new Trust guidelines that have removed the inquest and the new chart that has been introduced for the administration of unfractionated heparin. You have however raised further concerns with regards to the new Trust guidelines that have removed the requirement for a haematologist to be consulted where a patient is at the extremes of weight. The reasoning for this decision is as follows.” Source location 2015-0417-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Weight-based dosing, six-hour APTT checks and conditional haematology advice are considered sufficient safeguards without routine consultation for extreme patient weights.
Verbatim wording from the response “The Trust’s new policy is for a weight based bolus and then a weight based infusion the latter within weight ranges. Even with a patient of 25kg the infusion would be at 20iu/kg/hr which is a very reasonable infusion rate and in line with recognised dosage rates even at this weight. The APPTT must be checked at 6 hours and this allows the dose to be adjusted within recognised time intervals. We therefore feel that the safeguards are in place as we have moved to an entirely weight based formulation. As an extra safeguard the guideline, following the concerns you raised, now also states that if the APPTT at 6hrs is outside the expected range then the Consultant Haematologist should be contacted for further advice in those patients at the extreme ends of the weight ranges i.e. <41kg and >90kg.” Source location 2015-0417-Response
Open published response
9 Oct 2015 Patrick Joseph Carrick · Prevention of Future Deaths report Newcastle upon Tyne
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Concerns raised 1
Failure to action crucial blood analysis results View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Patrick Joseph Carrick · 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
Patrick Joseph Carrick underwent laparoscopic high anterior resection for colorectal cancer on 23 January 2012 and subsequently deteriorated, later dying from a rare but recognised complication of the surgery. Concerns included a significant unexplained departure from his management plan during rapid deterioration, failure to action blood analysis results, inadequate monitoring, delays in administering antibiotics, and inadequate completion of nursing and medical notes.
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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 action crucial blood analysis results
Wider context from the report “(1) There was a significant departure from a patients management plan without explanation
(2) The above was compounded as it occurred in a period of rapid deterioration
(3) Crucial blood analysis results were not actioned
(4) Inadequate completion of nursing and medical notes
” Source location Patrick Joseph Carrick · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use blood-result sheets in patient notes to record individual results and trends.
Verbatim wording from the response “"Actioning" of bloods on ICE requires that an action button is pressed on the ICE system for each blood result. This presents a conscious statement from the member of the medical team that they have viewed, interpreted and where clinically necessary, actioned the blood results. The key to the "actioning" of results is interpretation and integration into the patient's management plan and the following initiatives have or are being implemented to ensure that this continues to happen in a safe, consistent and effective manner:” Source location 2015-0374-Response-by-Northumbria-Health-Care-NHS-Trust
Open published response
25 Mar 2015 Bryan Herbert Whitby · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3
Failure of biochemistry laboratories to escalate blood test results View source Delays in recognising serious blood-test results View source Failure to admit patients as emergencies despite serious blood-test results View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Davyhulme Medical Centre Manchester 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. 7
Manchester University NHS Foundation Trust
Lower the creatinine alert threshold to 400 µmol/L and telephone qualifying results on the same day.
View source
Manchester University NHS Foundation Trust
Implement the Trust-wide acute kidney injury alert system, with same-day telephone escalation for Stage 3 alerts and case-by-case review of Stage 1 and 2 alerts.
View source
Davyhulme Medical Centre
Review the practice policy for allocating and checking incoming test results in light of the case.
View source
Davyhulme Medical Centre
Have all practice GPs read NICE guidance on acute kidney injury to improve management and awareness.
View source
Manchester University NHS Foundation Trust
Deliver acute kidney injury recognition and management training for junior and other relevant staff.
View source
Manchester University NHS Foundation Trust
Implement and disseminate acute kidney injury guidelines through Acute Medical Unit displays and the locum doctor handbook.
View source
Manchester University NHS Foundation Trust
Disseminate the case and its lessons through staff debriefing, Medical Grand Round and divisional audit and clinical effectiveness presentations.
View source See 4 more actions
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AI-generated summary
Bryan Herbert Whitby · 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
Bryan Herbert Whitby had chronic kidney disease and underwent a CT scan while his renal function was deteriorating and he was taking metformin. After the scan, further deterioration was identified, but there were delays and failures in escalating the results, arranging urgent admission, recognising his serious condition, providing treatment, and transferring him to the High Dependency Unit; he died shortly after admission there. The principal concerns included communication and escalation failures, inadequate recognition and treatment of acute illness, and delayed critical-care transfer.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of biochemistry laboratories to escalate blood test results
Wider context from the report “4. The results of the blood tests on the 6th May should have resulted in urgent discussion with the deceased’s GP or the deceased himself. There was no escalation of these results by the biochemistry laboratory .
” Source location Bryan Herbert Whitby · 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 Delays in recognising serious blood-test results
Wider context from the report “5. Despite the blood results, the deceased was not admitted to hospital as an emergency and there was a delay in recognising the seriousness of these results . I had given evidence that training for junior members of staff on acute kidney injury has now been delivered.
” Source location Bryan Herbert Whitby · 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 admit patients as emergencies despite serious blood-test results
Wider context from the report “5. Despite the blood results, the deceased was not admitted to hospital as an emergency and there was a delay in recognising the seriousness of these results. I had given evidence that training for junior members of staff on acute kidney injury has now been delivered.
” Source location Bryan Herbert Whitby · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lower the creatinine alert threshold to 400 µmol/L and telephone qualifying results on the same day.
Verbatim wording from the response “Mr Whitby's blood results were not escalated by the Chemical Pathology Laboratory on 06 May 2014 as the 500umol/L threshold followed in the Laboratory at that time for Creatinine had not been breached. Chemical Pathology have now lowered the telephoning limit for Creatinine results from 500umol/L to 400umol/L and these results are telephoned through on the same day.” Source location 2015-0121-Response-by-Central-Manchester-University-Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Trust-wide acute kidney injury alert system, with same-day telephone escalation for Stage 3 alerts and case-by-case review of Stage 1 and 2 alerts.
Verbatim wording from the response “Consultant Chemical Pathologist, ████████ and ████████, Chief Biomedical Scientist in Chemical Pathology, have confirmed that a review of the processes for urgently notifying GPs of abnormal test results has been undertaken. On 09 March 2015, the Biochemistry Department went live with an Acute Kidney Injury (AKI) alert system. In future all Stage 3 alerts will be telephoned as soon as possible on the same day. Stage 1 and 2 alerts will be reviewed on a case by case basis.” Source location 2015-0121-Response-by-Central-Manchester-University-Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the practice policy for allocating and checking incoming test results in light of the case.
Verbatim wording from the response “Mr Whitby’s case was discussed at a Significant Event meeting at the practice and has been further discussed by the GP’s and managers in recent weeks. Attached is a bullet point list of the actions that we have and will undertake related to this. In line with normal practice across the Primary care sector we have not in the past had a policy of checking every result on the day that it arrives. We have felt that there was a strong argument to maintain a level of continuity of care with results being seen by the GP who has ordered them but we have now reviewed this policy in light of Mr Whitby’s case.” Source location 2015-0121-Response-by-Davyhulme-Medical-Centre
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have all practice GPs read NICE guidance on acute kidney injury to improve management and awareness.
Verbatim wording from the response “It was also clarified that as a practice we are not able to see results put on to the hospital system automatically unless we search for them on a named patient basis. We do not automatically know about abnormal results in the hospital therefore. In fact ████████ who noted the abnormal results did ring the medical registrar to obtain further advice. As a result of the significant event meeting it was agreed that all GP’s would read the NICE Guidance on acute kidney injury to improve our management and awareness of this condition in the future. The need to consider stopping medication potentially toxic to the kidney in high risk patients was highlighted, as was the need to check blood results on a daily basis to avoid missing abnormal results.” Source location 2015-0121-Response-by-Davyhulme-Medical-Centre
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver acute kidney injury recognition and management training for junior and other relevant staff.
Verbatim wording from the response “Despite blood results, Mr Whitby was not admitted to hospital as an emergency and there was a delay in recognising the seriousness of these results. Training for junior members of staff on AKI has now been delivered.” Source location 2015-0121-Response-by-Central-Manchester-University-Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and disseminate acute kidney injury guidelines through Acute Medical Unit displays and the locum doctor handbook.
Verbatim wording from the response “The Trust's AKI guidelines, which support the recognition of severity and the management of AKI in line with NICE guidance August 2013, have been fully implemented and are clearly displayed on the Information Board and in the Doctors' office on the AMU. The guidelines are also now included in the Handbook provided to Locum Doctors.” Source location 2015-0121-Response-by-Central-Manchester-University-Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the case and its lessons through staff debriefing, Medical Grand Round and divisional audit and clinical effectiveness presentations.
Verbatim wording from the response “Medical and nursing staff on the Acute Medical Unit attended a debriefing session to discuss the care and treatment of Mr Whitby and the lessons learned. His case was also presented to medical staff at a Medical Grand Round and was presented more widely at the Divisional Audit and Clinical Effectiveness (ACE) day on 17 October 2014. The case was presented by ████████ Consultant, who discussed the missed opportunities and the chain of events. The presentation of Mr Whitby's case was followed by a presentation by ████████ Consultant in Nephrology and Intensive Care Medicine, who explained to staff how the Trust is tackling AKI. ████████ explained how AKI was a safety priority for the Trust and also explained the role of the Renal team and of the AKI Specialist Nurses.” Source location 2015-0121-Response-by-Central-Manchester-University-Hospital
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The practice relies on the laboratory to telephone urgent abnormal results, which are passed to the on-call doctor and dealt with that day.
Verbatim wording from the response “The practice relies upon the lab to phone through any abnormal results if urgent attention is required. These are then passed onto the on call doctor and are dealt with on the day. It was not felt practical to be able to guarantee to check all results as they come in continuously. Neither this nor the subsequent kidney function result was phoned through as urgent. We understood from the hospital critical incident report that the lab at Trafford General was aware of this and would be reviewing this system. It was also felt that in view of a previous drop in renal function to a lower level of 34, which had subsequently recovered, most of the GP’s felt they would have arranged to repeat the blood test in the first instance.” Source location 2015-0121-Response-by-Davyhulme-Medical-Centre
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The practice considers it impractical to guarantee that all results are checked continuously as they arrive.
Verbatim wording from the response “The practice relies upon the lab to phone through any abnormal results if urgent attention is required. These are then passed onto the on call doctor and are dealt with on the day. It was not felt practical to be able to guarantee to check all results as they come in continuously. Neither this nor the subsequent kidney function result was phoned through as urgent. We understood from the hospital critical incident report that the lab at Trafford General was aware of this and would be reviewing this system. It was also felt that in view of a previous drop in renal function to a lower level of 34, which had subsequently recovered, most of the GP’s felt they would have arranged to repeat the blood test in the first instance.” Source location 2015-0121-Response-by-Davyhulme-Medical-Centre
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The practice cannot automatically see hospital results and would need to search for them using a named-patient basis.
Verbatim wording from the response “It was also clarified that as a practice we are not able to see results put on to the hospital system automatically unless we search for them on a named patient basis. We do not automatically know about abnormal results in the hospital therefore. In fact ████████ who noted the abnormal results did ring the medical registrar to obtain further advice. As a result of the significant event meeting it was agreed that all GP’s would read the NICE Guidance on acute kidney injury to improve our management and awareness of this condition in the future. The need to consider stopping medication potentially toxic to the kidney in high risk patients was highlighted, as was the need to check blood results on a daily basis to avoid missing abnormal results.” Source location 2015-0121-Response-by-Davyhulme-Medical-Centre
Open published response
20 Jan 2015 Mrs Awa Jeng · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 2
Failure to ensure communication of requests for clinically required tests View source Failure to repeat blood tests within the required timeframe View source
This report raised 5 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
Barts Health NHS Trust
Add signing and dating requirements to orthopaedic handover sheets and retain them for audit and transparency.
View source
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AI-generated summary
Mrs Awa Jeng · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Awa Jeng was admitted after a fall that caused a fractured left hip and underwent surgery. She subsequently required dialysis but was not adequately monitored on the ward, and tests were delayed until her potassium was at a life-threatening level. She deteriorated, suffered cardiac arrest during intubation, and could not be resuscitated; the inquest concluded that inadequate monitoring and delayed haemofiltration contributed 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 Failure to ensure communication of requests for clinically required tests
Wider context from the report “3. The blood tests were not repeated until the following morning when they had deteriorated to a life threatening level.
4. It was not clear from the evidence why the blood tests were not repeated. The FY2 did write a retrospective note confirming that she had asked the on-call doctor to perform the test. Evidence from the on-call doctor denied that this information was passed on to her.
” Source location Mrs Awa Jeng · 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 repeat blood tests within the required timeframe
Wider context from the report “3. The blood tests were not repeated until the following morning when they had deteriorated to a life threatening level.
4. It was not clear from the evidence why the blood tests were not repeated. The FY2 did write a retrospective note confirming that she had asked the on-call doctor to perform the test. Evidence from the on-call doctor denied that this information was passed on to her.
” Source location Mrs Awa Jeng · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add signing and dating requirements to orthopaedic handover sheets and retain them for audit and transparency.
Verbatim wording from the response “There is a formal list and documentation for this meeting, an action plan for each patient and a record is kept and recorded on the sheet. This document forms the basis for the formal face-to-face handover meeting between the day and night medical teams.” Source location 2015-0015-Response-by-Barts-Health-NHS-Trust
Open published response
25 Jul 2014 Clare Serena Anke COOPER · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Failure to consider chemical pathology flagging of particularly concerning results View source
This report raised 13 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
Clare Serena Anke COOPER · 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
Clare Serena Anke Cooper, a young adult, developed weight loss, lassitude, dizziness, nausea, difficulty eating and an intermittently low blood sodium level before dying after a cardiorespiratory arrest and hospital admission. The inquest concluded that she died from the consequences of undiagnosed Addison’s disease and an Addisonian crisis. Principal concerns included inadequate assessment and documentation in primary care, failure to investigate the low sodium and possible physical causes, insufficient eating-disorder service triage processes, and inadequate information available for the post-mortem examination.
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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 consider chemical pathology flagging of particularly concerning results
Wider context from the report “4. No established system for recognition, assessment and management of electrolyte abnormalities within the GP practice and/or consideration of the chemical pathology service to ‘flag-up’ particularly concerning results .
” Source location Clare Serena Anke COOPER · Prevention of Future Deaths report
Open source report
15 May 2014 Gary Bradshaw · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure of the laboratory to flag blood-calcium levels from 3.0mmol/l View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Gary Bradshaw · 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
Gary Bradshaw attended hospital with groin pain and kidney stones, later developed hyperparathyroidism and died during a hospital admission. The report identified concerns including delays and errors in diagnosis and testing, prescribing bendroflumethiazide before blood-test results, discharge before full investigation, inadequate escalation and fluid monitoring, and incomplete clinical records.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the laboratory to flag blood-calcium levels from 3.0mmol/l
Wider context from the report “8. The hospital laboratory only ‘flag-up’ the blood-calcium levels exceed 3.5mmol/l or more of serum calcium. The expert witness opined that this should occur at levels of 3.0mmol/l , and that this should be the National standard.(Stockport NHS Trust and The Secretary of State)
” Source location Gary Bradshaw · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Escalate serum calcium results above 3 mmol/L through Trust laboratory processes.
Verbatim wording from the response “8. The hospital laboratory only “flag up” blood results if the blood calcium levels exceed 3.5mmol/L or more of serum calcium. The expert witness opined that this should occur at levels of 3.0mmol/L and that this should be a national standard
The escalation of serum calcium levels above 3mmol/L was introduced into Trust processes in March 2014.” Source location 2014-0232-Response-2
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE does not stipulate laboratory reference values or alert thresholds because this falls outside its remit.
Verbatim wording from the response “In response to your concerns about the reporting of blood test results, NICE do not stipulate laboratory reference values or ‘flags’ on when to alert clinicians to blood test results. As this is not something that falls within NICE’s remit, it is for individual NHS Trusts to review their own standards.” Source location 2014-0232-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual NHS Trusts are responsible for reviewing their own standards for laboratory result reporting and alerts.
Verbatim wording from the response “In response to your concerns about the reporting of blood test results, NICE do not stipulate laboratory reference values or ‘flags’ on when to alert clinicians to blood test results. As this is not something that falls within NICE’s remit, it is for individual NHS Trusts to review their own standards.” Source location 2014-0232-Response-by-Department-of-Health
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.