Recurring concern

Inadequate preoperative assessment of surgical suitability and risk

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First reported 18 Oct 2013•Latest report 12 Nov 2025

Definition

What this concern includes

Includes failures to assess surgical suitability, comorbidity, operative risk or the need for preoperative investigation or optimisation.

Not included

  • Excludes generic medication prescribing, monitoring or supply failures not directly part of preoperative surgical assessment or consent.
  • Excludes standalone VTE, anticoagulation or diagnostic-testing failures when they are not tied to a preoperative surgical decision or consent process.
  • Excludes postoperative care, discharge planning and treatment-selection failures outside the preoperative assessment and consent process.
  • Excludes generic staffing, communication, documentation or training deficiencies unless the source explicitly connects them to the safety of preoperative assessment or consent.
Reports
13

Distinct published reports

Individual concerns
17

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
9

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care4
St Peter's Hospital2
Barts Health NHS Trust1
British Society For Dermatological Surgery1
Care Quality Commission1
East Kent Hospitals University NHS Foundation Trust1
Goring Hall Hospital1
NHS Blood and Transplant1
NHS Surrey and Sussex Integrated Care Board1
Regenesis Health Travel Ltd1
Royal College of Anaesthetists1
Royal College of Surgeons of England1
Royal London Hospital1
Sandwell and West Birmingham Hospitals NHS Trust1
Stepping Hill Hospital1

Concerns and responses across reports

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

  1. Central and South East Kent

    AI-generated summary

    Betty SMITH · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Betty SMITH underwent surgery for a large intrathoracic hiatus hernia on 22 October 2012, deteriorated the following day, was admitted to intensive care on 24 October, and died on 25 October from intraabdominal and intrathoracic haemorrhage following repair of the hiatus hernia. Concerns included the lack of a secured High Dependency Unit bed before surgery, inadequate anaesthetic pre-assessment and the failure to refer her to a tertiary centre. The report also identified reduced intensive care capacity due to closed beds and nursing shortages as compromising care.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate pre-operative anaesthetic assessment of high-risk patients

    Wider context from the report

    “• The pre-assessment service offered by the Anaesthetic Department is far from adequate. To review such a high risk patient with significant comorbidity from the medical records is not in the patient’s interest. Time should be afforded to the anaesthetists to review the patient at an out-patient clinic pre-operatively to assess the risks and discuss them. ”

    Source location

    Betty SMITH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Berkshire

    AI-generated summary

    Mrs Nutbeam · 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 Nutbeam was struck by a car and later underwent debridement surgery for an infected leg wound. She vomited and aspirated during the procedure and subsequently died; the principal concerns were failures to transfer information about her vomiting between hospitals and to record or communicate vomiting symptoms before surgery, together with whether pre-operative questioning should routinely address recent vomiting.

    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 routinely ask patients about vomiting within the previous twenty-four hours before surgery

    Wider context from the report

    “(4) It was also given in evidence at the Inquest that, when the Anaesthetist visited Mrs Nutbeam prior to the surgery and explained the procedure, the risks and took her consent, he did not ask her if she had vomited within the last twenty four hours. The evidence was that this is not a standard question to ask of patients ahead of surgery. ”

    Source location

    Mrs Nutbeam · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Jennifer Elsie RUSHWORTH · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    The circumstances of Jennifer Elsie Rushworth's death are not included in the supplied text. Concerns raised at the inquest included delays in cardiology review and surgery, insufficient surgical staffing, and questions about surgical clips used to clip blood vessels.

    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 cardiology review for patients proposed for surgery

    Wider context from the report

    “The first of the issues that he raised was the fact that it is quite normal for cardiology review to take anything up to six months to come through to the surgeon proposed to operate on the patient. In this particular instance the first consultation with the surgeon took place on 5 July 2012 and in view of her cardiac history he referred her to the cardiologist for cardiac optimisation review. Report back from the cardiologist came on 28 January 2013. It seems to me unsatisfactory that this length of time should elapse for cardiology reviews in these circumstances. ”

    Source location

    Jennifer Elsie RUSHWORTH · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026