Recurring concern

Failure to ensure required surgical team coverage throughout operations

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First reported 7 Jan 2022•Latest report 22 Jan 2024

Definition

What this concern includes

Includes failures in the dedicated surgical-planning and theatre-coverage process that result in a required surgeon being absent, leaving before the operation is complete, or not being replaced or escalated when coverage is lost.

Not included

  • Excludes generic surgical staffing shortages or workforce-capacity concerns where required operative coverage is not the identified unsafe condition.
  • Excludes poor operation planning, theatre booking or attendance failures that do not concern ensuring required surgical team coverage during the operation.
  • Excludes failures in clinical decisions, handover or communication after adequate surgical coverage has been maintained.
  • Excludes postoperative care and ordinary staff absence unrelated to required coverage for an operation.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2022–2024

First to latest report issue date

Stated actions
0

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.

Barts Health NHS Trust1
Department of Health and Social Care1
Recipient name withheld1
Royal College of Anaesthetists1
Royal College of Surgeons of England1
Royal London Hospital1
The James Cook University 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. Teesside and Hartlepool

    AI-generated summary

    Kate Elizabeth O’Donnell · 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

    Kate Elizabeth O’Donnell underwent surgery on 16 March 2022 and was discharged the following day. She developed sepsis from the surgery, originating in her gut, and died at James Cook University Hospital on 23 March 2022. Principal concerns included inadequate surgical planning, failure to provide appropriate prophylactic antibiotics for the gastrointestinal surgery, insufficient postoperative vigilance and assessment before discharge, incomplete nursing records, and inadequate discharge information.

    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 operation planning to ensure colorectal surgeon attendance

    Wider context from the report

    “1. Planning for the operation was poor and resulted in the non-attendance of a colorectal surgeon at the surgery. ”

    Source location

    Kate Elizabeth O’Donnell · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Appropriate surgical planning took place; the principal failure was poor recording of decisions and delayed access to notes.

    Verbatim wording from the response

    “The Consultant Urologist wrote to the Consultant Surgeon on two occasions regarding Kate’s surgery. This was to discuss whether help would be required from the Consultant Surgeon in case Kate’s bowel needed to be mobilised during the surgery. The ACE stoma removal was a similar, but less invasive surgery to an appendectomy. The Consultant Urologist and General Surgeon had a verbal conversation and agreed that full bowel mobilisation and/or laparotomy was not required as the ACE stoma could be accessed via the abdominal wall exit site, and as such the procedure could be undertaken by the Consultant Urologist. Unfortunately, this conversation is not recorded in the medical notes, and although both parties confirm it occurred, neither can confirm the date. However, the coroner’s statement provided by the Consultant Urologist highlights that the conversation took place on the day of surgery.”

    Source location

    Response from South Tees Hospitals
    Page 2 · response
    Published 25 January 2024

    Open published response

  2. East London

    AI-generated summary

    Mrs Surekha Pandharinath Shivalkar · 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 Surekha Pandharinath Shivalkar, aged 78, underwent revision total hip replacement surgery and subsequently developed profound hypotension, multiorgan failure and cardiac arrest, dying despite intensive treatment. Concerns included the absence of a formal preoperative risk assessment tool, poor communication between the surgical and anaesthetic teams, and inadequate systems concerning the senior surgeon’s departure before the operation concluded.

    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 effectively monitor when a surgeon leaves theatre

    Wider context from the report

    “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre. ”

    Source location

    Mrs Surekha Pandharinath Shivalkar · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
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Data last updated 7 September 2026