Recurring concern

Unreliable and delayed surgical referral and review

First to latest report 25 Feb 2014 — 29 Dec 2023

Reports that mention this concern
12
Times this concern has been raised
14
Stated actions linked to this concern
16

What this concern includes

Includes failures of the surgical referral-and-review process, including referral completion, handover, escalation, availability or responsiveness of surgical services, and timeliness of review, where these failures prevent or delay required surgical input.

What is not included
  • Excludes generic delays in treatment, imaging, transfer or other clinical processes without a direct surgical referral or review connection.
  • Excludes failures concerning postoperative follow-up or ongoing oversight after discharge when they are not part of an outstanding surgical referral or review.
  • Excludes documentation, training or staffing deficiencies that are not specifically tied to failure of the surgical referral-and-review process.

Reports and published responses 12 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Black Country

    AI-generated summary

    Karmchand Gulzar · 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

    Karmchand Gulzar was taken to Sandwell Hospital on 23 September 2022 with abdominal distension and pain and was diagnosed with acute intestinal obstruction. A CT scan and immediate surgical review were delayed; his condition deteriorated, urgent surgery took place during the evening and early morning, and he died during the operation in the early hours of 24 September 2022. Concerns included failure to follow the surgical registrar referral pathway, failure to undertake an urgent CT scan, and insufficient recognition of deterioration and concerns raised by carers and family about his condition.

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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 utilise the surgical registrar referral pathway

    Wider context from the report

    “(1) Karmchand was referred to the surgical nursing team instead of the surgical registrar or surgical on-call team, as required by the Emergency Department to surgical registrar referral pathway from a previous SI where it had been identified as an issue. This was not followed in this case, leading to a delay in surgery and increased risk of death. I am concerned that the surgical registrar referral pathway is not being utilised despite previous incidents in which its use was highlighted as necessary. ”

    Source location

    Karmchand Gulzar · Prevention of Future Deaths report
    Page 3 · concerns

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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

    Update and reissue the acute abdomen guideline with a pathway flowchart, early CT emphasis, and mandatory consultant discussion before surgical referral.

    Verbatim wording from the response

    “The Management of Acute Abdomen guideline that was in use at the time of this incident has been updated and re-issued in June 2023. This guideline was created in consultation with the Doctors working within the Emergency Department and the Patient Safety team, to ensure the appropriate learning is incorporated into the process. The guideline aligns with the BMJ Best Practice recommendations.”

    Source location

    Response from Sandwell and West Birmingham NHS Trust
    Page 1 · response
    Published 3 January 2024

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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

    Embed the updated acute abdomen guidance through staff dissemination, intranet publication, team discussions, induction and teaching, handover reminders, and anonymised case-learning discussions.

    Verbatim wording from the response

    “In order to embed the new guideline, it has been sent to all applicable staff, published on our intranet site and discussed within team meetings and appropriate forums. The guidance is highlighted at induction sessions for new doctors and in appropriate teaching sessions. Staff have also been reminded to include outstanding referrals at the handover discussion. Mr Gulzar’s case has also been anonymised and discussed with the clinical teams within the Emergency and”

    Source location

    Response from Sandwell and West Birmingham NHS Trust
    Page 1 · response
    Published 3 January 2024

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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

    Audit the acute abdomen pathway to assess the effectiveness of the updated guidance and related safety activities.

    Verbatim wording from the response

    “Surgical departments to ensure our teams are aware of the learning from this case. To assess the efficacy of the activities described above, an audit of the Acute Abdomen pathway is planned in March 2024.”

    Source location

    Response from Sandwell and West Birmingham NHS Trust
    Page 2 · response
    Published 3 January 2024

    Open published response

  2. Newcastle and North Tyneside

    AI-generated summary

    Brian David MORETON · 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

    Brian Moreton was admitted with diarrhoea, recurring fever and a distended abdomen; a toxic megacolon present on CT was not reported to those treating him. He was treated for severe colitis, later found to have a perforated bowel, and died from infections following surgery and immunosuppression. The principal concern was poor and misleading communication between clinicians, departments and hospital trusts, including deficiencies in the information provided to radiologists and assumptions about his clinical improvement and surgical referral.

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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 complete required referral for surgical opinion

    Wider context from the report

    “- Evidence was heard that at the time of the inquest radiologists do not have access to patient' medical notes and base their reporting on a summary document submitted by the department requiring imaging. The summary document in Mr MORETON’S case was seen to be deficient in that it omitted his symptom of fever. It was heard in evidence a radiologist would need to telephone the department in question or go there to inspect the notes. Their awareness of a patient's condition is based on a telephone call referral followed by a summary document which can be at odds with each. - It is of concern that the use of telephone referral system and summary could contain errors and the radiologist must rely on this information, with no quick way to inspect a patient's notes. - The evidence also dealt with radiologists working in 2 hour triage shifts in a hectic environment where those clinicians receiving the referral seldom were the clinicians who carried out the imaging. The inference was the arrangement was susceptible to error. - Over the course of the inquest evidence was heard on a number of issues where information passed to and from clinicians involved in Mr MORETON’S care was inaccurate and misleading. - Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect. - It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place. - Clinicians in Newcastle Upon Tyne when asked for advice were under the impression treatment was working as it was mentioned his discharge from hospital was contemplated - this was not the case. - Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care. ”

    Source location

    Brian David MORETON · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Develop and ratify an inflammatory bowel disease SOP covering acute severe colitis red flags, toxic megacolon and specialist referrals.

    Verbatim wording from the response

    “A standard operating procedure (SOP) is in the final stages of development for the management of inflammatory bowel disease (IBD), including the general management of acute severe colitis of all causes. The SOP includes red flag symptoms for acute severe colitis, and makes regular reference to the need for clinicians to be cognisant of high-risk features and devastating complications of severe colitis, such as toxic megacolon. The SOP provides education that toxic megacolon is characterised by radiographic distension of the colon often with fever, tachycardia, neutrophil leucocytosis and anaemia. Once ratified the SOP will be electronically accessible to all clinical teams via the Trust’s Clinical SOPs intranet page.”

    Source location

    Response from North Cumbria Integrated Care NHS Foundation Trust
    Page 4 · response
    Published 5 October 2023

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Hold joint internal and cross-Trust IBD multidisciplinary meetings at established biweekly and triweekly frequencies.

    Verbatim wording from the response

    “The Trust now holds joint biweekly IBD multidisciplinary team meetings (MDTs) between the internal general surgery and gastroenterology teams. A triweekly joint specialist IBD MDT between the Trust and Newcastle upon Tyne Hospitals NHS Foundation Trust has also been established since February 2023. An MDT, made up of a variety of specialists within an interest in IBD or gastroenterology, approach to the management of a patient’s IBD, is recommended to provide optimised and personalised care, based on available professional expertise, infrastructure and funding, and helps to prevent errors in the delivery of care and avoid related harm to patients. The timing of MDT meetings happen on the aforementioned frequencies to ensure decision-making is not delayed, however, such discussions largely relate to complex, chronic IBD patients.”

    Source location

    Response from North Cumbria Integrated Care NHS Foundation Trust
    Page 7 · response
    Published 5 October 2023

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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

    Timetabled multidisciplinary team meetings cannot determine acute or emergency care because those decisions cannot be delayed.

    Verbatim wording from the response

    “Acute or emergency care decisions cannot not be delayed for timetabled MDTs, but should happen separately between relevant specialists. The introduction of the MDTs has improved working relationships and communication between the teams and Trusts, to ensure early referrals for specialist input in the management of a patient’s care is sought, for patients who are acutely unwell and/or where urgent advice is required. Had the MDTs been in place during Mr Moreton’s admission, he likely would have been listed for discussion in both MDTs and professional relationships would have been established to seek earlier input from surgical colleagues and specialists in Newcastle.”

    Source location

    Response from North Cumbria Integrated Care NHS Foundation Trust
    Page 7 · response
    Published 5 October 2023

    Open published response

  3. East London

    AI-generated summary

    Daniel Xavier · 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

    Daniel Xavier attended the emergency department on 21 October 2021 with a history of painful haemorrhoids and an accompanying history of constipation. A venous blood gas showed an abnormally high creatinine level, but the result was not considered before he was discharged; he later became increasingly unwell, suffered a cardiac arrest, and could not be resuscitated. The report identified concerns about the failure to act on the blood result, a chaotic referral and inadequate handover, and insufficient consideration of his learning disability when taking his history.

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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 provide effective referral communication and formal handover to the surgical team

    Wider context from the report

    “2. Mr Xavier’s referral to the surgical team by his GP was chaotic. No telephone contact was made between the GP and the on call surgical team. Mr Xavier was therefore triaged by a ED nurse and subsequently, a rapid assessment team junior doctor before he was brought to the attention of the surgical team. Despite these assessments, no formal handover was provided to the surgical team, setting out the extent of the history, clinical observations and diagnostic processes that had previously taken place. Despite these shortcomings, the surgical team accepted the referral without considering Mr Xavier’s clinical records beforehand. ”

    Source location

    Daniel Xavier · Prevention of Future Deaths report
    Page 2 · concerns

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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 review clinical records before accepting a surgical referral

    Wider context from the report

    “2. Mr Xavier’s referral to the surgical team by his GP was chaotic. No telephone contact was made between the GP and the on call surgical team. Mr Xavier was therefore triaged by a ED nurse and subsequently, a rapid assessment team junior doctor before he was brought to the attention of the surgical team. Despite these assessments, no formal handover was provided to the surgical team, setting out the extent of the history, clinical observations and diagnostic processes that had previously taken place. Despite these shortcomings, the surgical team accepted the referral without considering Mr Xavier’s clinical records beforehand. ”

    Source location

    Daniel Xavier · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Work with primary-care colleagues to improve the referral system.

    Verbatim wording from the response

    “The Trust is working with senior colleagues from primary care to improve the system. Consideration is being given to introducing a single referral telephone line where calls are screened and accepted. We expect to have agreed a system by the end of October 2022. The principle will be that there is automatic acceptance of referrals from GPs.”

    Source location

    Response from Barts Health NHS
    Page 2 · response
    Published 23 September 2022

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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

    Consider introducing a screened single referral telephone line with automatic acceptance of GP referrals.

    Verbatim wording from the response

    “The Trust is working with senior colleagues from primary care to improve the system. Consideration is being given to introducing a single referral telephone line where calls are screened and accepted. We expect to have agreed a system by the end of October 2022. The principle will be that there is automatic acceptance of referrals from GPs.”

    Source location

    Response from Barts Health NHS
    Page 2 · response
    Published 23 September 2022

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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

    Develop internal professional standards for specialty teams reviewing emergency-department patients, including training on locating relevant electronic records information.

    Verbatim wording from the response

    “The site is developing internal professional standards for speciality teams reviewing patients in the emergency department. This will include training on where to find all relevant information including tests carried out and GP consultation within the electronic patient records system. The expectation is to have these agreed by the end of October 2022.”

    Source location

    Response from Barts Health NHS
    Page 2 · response
    Published 23 September 2022

    Open published response

  4. Surrey

    AI-generated summary

    ARTHUR FREDERICK HALL · 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

    Arthur Frederick Hall developed a perforation following an elective colonoscopy with polypectomy on 31 January 2018. He was discharged from A&E after presenting with abdominal symptoms, later returned with sepsis and underwent emergency surgery, but died on 2 March 2018 from overwhelming sepsis and multiple organ failure. The principal concerns included inadequate investigation and assessment of possible bowel perforation, unclear discharge advice, failure to obtain surgical input, and missed signs of sepsis.

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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 seek surgical opinion for suspected post-surgical symptoms

    Wider context from the report

    “6. No surgical opinion was sought when a surgical patient attended A&E with symptoms which were suspected to be related to surgery. ”

    Source location

    ARTHUR FREDERICK HALL · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  5. Lancashire and Blackburn with Darwen

    AI-generated summary

    Mr Frank Charles Medley · 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 Frank Charles Medley presented with acute weakness in all four limbs, but an MRI scan that was considered urgent was delayed for four working days. He underwent surgery for multiple paraspinal abscesses and died on 14 July 2019. The principal concerns included delays and inadequate prioritisation of imaging, deficiencies in the Trust’s adverse incident review, and shortcomings in systems for detecting adverse outcomes and coordinating relevant departments.

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    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 expedite scanning or contact tertiary neurosurgical services after specialist input

    Wider context from the report

    “(2) The Trust's review of this case was seriously deficient in the following instances: a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest. b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance; c. The case was inappropriately allocated to a structured judgement review; d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading; e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that: i. the EWS score was sufficient to trigger the septic shock pathway; ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor"; iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust); iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest; v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event. f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan; g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services; h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG; i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation; j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day. k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need; l. There was insufficient senior clinical oversight of the conclusions drawn. ”

    Source location

    Mr Frank Charles Medley · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Operate a year-round radiology inpatient coordinator or navigator function to improve referral communication, patient flow and scan escalation.

    Verbatim wording from the response

    “Radiology in-patient Co-ordinator/Navigator role was established in November 2019. This role has supported improved patient flow and communication between referring clinical teams and the radiology team. Cover is provided 52 weeks of the year by the Radiology Administrative function. A Standard Operating Procedure describing the functions of this role and the actions required by referrers to improve access and efficiency in radiology is being developed to support this function. Communications have been clarified to advise on the most appropriate manner for teams to access the In-patient Navigator. This is the route that teams will use to find out when a scan is planned and also to expedite imaging which has not yet been planned.”

    Source location

    2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
    Page 4 · response
    Published 8 March 2021

    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 standard operating procedure defining navigator functions and referrer actions for radiology access and efficiency.

    Verbatim wording from the response

    “Radiology in-patient Co-ordinator/Navigator role was established in November 2019. This role has supported improved patient flow and communication between referring clinical teams and the radiology team. Cover is provided 52 weeks of the year by the Radiology Administrative function. A Standard Operating Procedure describing the functions of this role and the actions required by referrers to improve access and efficiency in radiology is being developed to support this function. Communications have been clarified to advise on the most appropriate manner for teams to access the In-patient Navigator. This is the route that teams will use to find out when a scan is planned and also to expedite imaging which has not yet been planned.”

    Source location

    2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
    Page 4 · response
    Published 8 March 2021

    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

    Hold twice-weekly clinico-radiological meetings to discuss difficult cases and support imaging decisions without requiring personal attendance.

    Verbatim wording from the response

    “Clinico-radiological meetings were established in November 2020 and now occur twice weekly on Monday and Friday on AMU. It is intended that when possible, a third meeting will be provided on a Wednesday to provide better support through the working week. This development allows a forum in which difficult cases can be discussed and advice and guidance provided on the optimum imaging technique and/or interpretation of unusual report findings and has been a significant success; building improved relationships and communication between clinical teams on AMU and the radiology directorate. This meeting explicitly addresses the human factors highlighted in this case; ensuring that patient management is equitable regardless of the staff on duty and that clinical discussions can be held without personal attendance.”

    Source location

    2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
    Page 4 · response
    Published 8 March 2021

    Open published response

  6. West Yorkshire Eastern

    AI-generated summary

    Sharon Jamela Reeve · Prevention of Future Deaths report

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

    Report summary

    Sharon Jamela Reeve developed a persistent headache, underwent investigations and was discharged after an electronic referral to a tertiary neurosurgical unit. She was found unresponsive on 10 March 2018, underwent emergency surgery and died on 14 March 2018. The principal concerns were unclear referral pathways, incomplete and ineffective communication between hospitals, delays in specialist review, and inadequate clarity about the electronic referral system.

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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

    Referral routing failing to provide radiologists’ reports

    Wider context from the report

    “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life. The pertinent features of the miscommunication were: 1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists). 2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed. 3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them. 4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding. 5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images. ”

    Source location

    Sharon Jamela Reeve · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Lack of firm rules requiring image review before referral responses

    Wider context from the report

    “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life. The pertinent features of the miscommunication were: 1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists). 2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed. 3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them. 4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding. 5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images. ”

    Source location

    Sharon Jamela Reeve · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Staffordshire South

    AI-generated summary

    Gwendoline Edith Halfpenny · 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

    Gwendoline Edith Halfpenny fell and broke her left arm on 1 September 2016, was admitted to County Hospital with bowel problems on 6 September, and died in hospital on 13 September after her condition deteriorated and major surgery was performed. The concerns were the lack of surgical cover at County Hospital and differences in monitoring systems, policies and equipment between County Hospital and the Royal Stoke University Hospital.

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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

    Lack of surgical cover at County Hospital

    Wider context from the report

    “1. Soon after her arrival at County Hospital Mrs Halfpenny would have benefitted from surgical input. There was no surgical cover at County Hospital. Remote advice from RSUH is not the same as a surgical presence and I wonder if there should be a mid-grade surgical doctor at County Hospital. ”

    Source location

    Gwendoline Edith Halfpenny · Prevention of Future Deaths report
    Page 1 · concerns

    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

    Realign surgical services so County Hospital has no inpatient general surgery and senior surgeons remain available on site through continuing day-case services.

    Verbatim wording from the response

    “1. At the time of the integration of UHNS and MFST and the re-modelling of services following the closure of MFST, the University Hospitals of North Midlands undertook a substantial amount of work to ensure that services were reviewed and realigned to those sites more suitable to provide the best environment. As a result of this, with effect from 9 February 2015 there were to be no in-patient services at the County Hospital under the care of general surgery (including gastro-intestinal (GI), breast and vascular surgery). However, day case surgeries under other specialties continue to provide a service from this site, so senior surgeons are available.”

    Source location

    2017-0353-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
    Page 2 · response
    Published 11 February 2018

    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 operate a surgical referral procedure providing on-site consultant coverage, same-day review efforts, and direct referral access to the responsible consultant.

    Verbatim wording from the response

    “In February 2015 a Standard Operating Procedure (SOP) to address the surgical referral system was introduced and provides the following:”

    Source location

    2017-0353-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
    Page 2 · response
    Published 11 February 2018

    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 consultant surgeons and the surgical referral procedure provide surgical availability at County Hospital, so additional mid-grade surgical cover is not indicated.

    Verbatim wording from the response

    “1. At the time of the integration of UHNS and MFST and the re-modelling of services following the closure of MFST, the University Hospitals of North Midlands undertook a substantial amount of work to ensure that services were reviewed and realigned to those sites more suitable to provide the best environment. As a result of this, with effect from 9 February 2015 there were to be no in-patient services at the County Hospital under the care of general surgery (including gastro-intestinal (GI), breast and vascular surgery). However, day case surgeries under other specialties continue to provide a service from this site, so senior surgeons are available.”

    Source location

    2017-0353-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
    Page 2 · response
    Published 11 February 2018

    Open published response

  8. Inner North London

    AI-generated summary

    Bronwyn Ann WILLIAMS · 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

    Bronwyn Williams died on 23 May 2017 from a retropharyngeal abscess after attending hospital and a dentist with severe restricted mouth opening and malaise. The concerns included the use of postal referral for an urgent maxillofacial appointment and the failure to provide an appointment within two weeks; the appointment was ultimately scheduled nearly seven weeks after referral and Ms Williams died before being seen.

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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

    Delays in arranging maxillofacial appointments after referral

    Wider context from the report

    “2. Following Ms Williams’ attendance at the dental surgery on 4 May, an appointment with the maxillofacial unit was made for 30 May, then cancelled by the Homerton on 23 May and re-fixed for 19 June. This date is nearly seven weeks post referral. ”

    Source location

    Bronwyn Ann WILLIAMS · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  9. Northamptonshire

    AI-generated summary

    Pamela Keech · 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 Keech, who had end-stage renal failure and received haemodialysis through a leg graft, experienced repeated bleeds from the graft site before being found unconscious with substantial blood loss on 7 July 2015. She died from a catastrophic haemorrhage from the graft site. Concerns included the lack of national guidance and training on predicting and managing fatal graft or fistula haemorrhage, and whether patients with such bleeds are escalated for renal or surgical review.

    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 escalate fistula/graft-site bleeds for renal or surgical review

    Wider context from the report

    “(3) I am concerned that other patients presenting with bleeds from fistula/graft sites might not be escalated for renal/surgical review before a fatal bleed presents. ”

    Source location

    Pamela Keech · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Request an expert review of UK ambulance clinical practice guidelines for renal patients, specifically covering fistula bleeds.

    Verbatim wording from the response

    “The action that we will be taking is to request that JRCALC, acting as our expert clinical advisors, review the UK ambulance service clinical practice guidelines for the management of renal patients and specifically in relation to fistula bleeds. We will ensure that any recommendations for new or updated guidance is written, published and issued to our ambulance clinicians as part of our ongoing clinical practice guideline development plan.”

    Source location

    2017-0327-Response-by-Association-of-Ambulance
    Page 1 · response
    Published 2 December 2017

    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

    Write, publish and issue any resulting new or updated fistula-bleed guidance to ambulance clinicians through the clinical practice guideline development plan.

    Verbatim wording from the response

    “The action that we will be taking is to request that JRCALC, acting as our expert clinical advisors, review the UK ambulance service clinical practice guidelines for the management of renal patients and specifically in relation to fistula bleeds. We will ensure that any recommendations for new or updated guidance is written, published and issued to our ambulance clinicians as part of our ongoing clinical practice guideline development plan.”

    Source location

    2017-0327-Response-by-Association-of-Ambulance
    Page 1 · response
    Published 2 December 2017

    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

    Seek specialist advice from the Vascular Access Society of Britain & Ireland on fistula bleeds and hospital conveyance when bleeding has stopped.

    Verbatim wording from the response

    “In addition, have written to the Vascular Access Society of Britain & Ireland to seek specialist advice in relation to fistula bleeds and whether patients should always be conveyed to hospital, particularly when bleeding has stopped. There may be opportunities to develop pathways for our clinicians to have direct clinical discussions with a vascular specialist regarding the most appropriate pre-hospital management of a patient and to agree whether conveying the patient to hospital is required.”

    Source location

    2017-0327-Response-by-Association-of-Ambulance
    Page 1 · response
    Published 2 December 2017

    Open published response

  10. Inner North London

    AI-generated summary

    Shalini GANESH-RAM · 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

    Shalini Ganesh-Ram died in the Royal London Hospital on 11 August 2015 after developing Ogilvie’s syndrome following a Caesarean section, which led to a perforated caecum. The concerns included delayed diagnosis of the perforation, delays in CT scanning and surgical consultation, and inappropriate use of the modified obstetric early warning score to identify sepsis.

    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 seek surgical consultation following concerning CT findings

    Wider context from the report

    “3. Several obstetric registrars were aware that the CT scan revealed a large volume in the peritoneum, but did not then seek a surgical consult, perhaps because the radiology registrar described no bowel wall defect having been demonstrated. I heard that the report of the radiology consultant the following day was felt to provide a clearer warning of perforation. ”

    Source location

    Shalini GANESH-RAM · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026