Concerns raised 1
Confusing medical-record format preventing sequential recording of entries View source
This report raised 8 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
Herbert Chandler · 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
Herbert Chandler was admitted to William Harvey Hospital with chronic obstructive pulmonary disease and a left pneumothorax. On 22 January 2013, an attempt to aspirate the left pneumothorax mistakenly aspirated the right lung first, after which the left lung was aspirated and he died soon afterwards. The concerns included the conservative management of the pneumothorax, medication prescribing, failures in clinical review and communication, the aspiration procedure, medical record format, and respiratory consultant cover.
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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 Confusing medical-record format preventing sequential recording of entries
Wider context from the report “A series of failings by the Trust have caused or contributed to the cause of death, namely:-
• A conservative approach to managing the left pneumothorax with antibiotics,
• Inappropriate prescribing of medication, namely gentamicin and aminophylline,
• A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician,
• A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team,
• The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray,
• The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung,
The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology,
• A confusing format of medical records which prevented sequential recording of entries by health care professionals ,
• A failure to provide Consultant on call respiratory cover.
” Source location Herbert Chandler · Prevention of Future Deaths report
Open source report
25 Jul 2014 Clare Serena Anke COOPER · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Poor GP documentation View source
This report raised 13 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. 2
Woodlands Surgery
Fully document consultations, including relevant histories, examinations and clinically relevant routine vital signs.
View source
Woodlands Surgery
Submit anonymised consultation notes for assessment during doctors’ next appraisals.
View source
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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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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Poor GP documentation
Wider context from the report “1. Poor GP documentation
” Source location Clare Serena Anke COOPER · 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 Fully document consultations, including relevant histories, examinations and clinically relevant routine vital signs.
Verbatim wording from the response “We have all agreed that all consultations should be fully documented in the patients’ notes. All patients should have a proper assessment of their history and a full examination should be done and routine vital signs should be recorded if they are clinically relevant.” Source location 2014-0345-Response-by-Woodlands-Surgery
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 Submit anonymised consultation notes for assessment during doctors’ next appraisals.
Verbatim wording from the response “We have all agreed that the notes keeping in this case should have been better and may have compounded the issue relating to lack of continuity of care. In order to improve patient care and ensure that an episode like this is not repeated, doctors at the practice have agreed that as part of their ongoing personal development plan to submit anonymised consultation notes for their next appraisals. This will give a chance for each individual doctor’s appraiser to assess the quality of note keeping.” Source location 2014-0345-Response-by-Woodlands-Surgery
Open published response
Concerns raised 1
Failure of drug charts to indicate the precise dispensed tramadol dose View source
This report raised 3 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
Kathleen Cornthwaite · 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
Kathleen Cornthwaite, aged 76, was an inpatient at Pendle Community Hospital when her tramadol prescription was increased after a fall causing a rib injury. The inquest concluded that she died of cardiorespiratory failure due to combined tramadol and fluoxetine toxicity. Concerns included the imprecise tramadol dose recorded, failure to account for her age, size and frailty, and failure to consider interactions with other prescribed medicines.
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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 of drug charts to indicate the precise dispensed tramadol dose
Wider context from the report “1. That the drug chart failed to indicate the precise dose of tramadol dispensed .
” Source location Kathleen Cornthwaite · Prevention of Future Deaths report
Open source report
16 Jul 2014 Julie Ann Robertson · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Poor record keeping View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Julie Ann Robertson · 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
Julie Ann Robertson died on 11 May 2013 from complications following an operation for an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. The inquest narrative described delays in escalation, obtaining blood and starting surgery, as well as poor record keeping and unclear timings. The report raised concerns that matched blood was not immediately available on the ward and that there was insufficient formal training in record keeping.
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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 Poor record keeping
Wider context from the report “2) Record keeping was poor and this was acknowledged in the Root Cause Analysis report. Although I heard evidence that there had been some training instigated there is no formal training and indeed witnesses at the inquest still seemed unaware of good practice as to record keeping.
” Source location Julie Ann Robertson · Prevention of Future Deaths report
Open source report
7 Jul 2014 Harold George de Mello · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Inconsistent recording between assessments and correspondence View source
This report raised 8 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
Harold George de Mello · 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
Harold George de Mello, who had multiple co-morbidities, limited mobility and incontinence, died in hospital on 13 April 2014 after collapsing at home and being treated for bronchopneumonia. The principal concerns were that social-care assessments did not adequately investigate or record the reported incontinence, hygiene problems, care arrangements and differing information, and lacked sufficiently comprehensive guidance and senior review.
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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 Inconsistent recording between assessments and correspondence
Wider context from the report “(5) that there was a difference in the actions recorded in the assessment (apparently the ordering of urine bottles) and the letter written to Mr de Mello stating that a commode had been ordered and no consideration of whether he could use a commode
” Source location Harold George de Mello · Prevention of Future Deaths report
Open source report
4 Jul 2014 Stanley Bere · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Failure to properly complete Cardex records 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
The Salvation Army
Strengthen incident reporting by recording and updating falls, accidents and near misses, with regular management auditing and follow-up.
View source
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AI-generated summary
Stanley Bere · 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
Stanley Bere, a resident of a nursing home, fell on 31 October 2011 and sustained a fractured ankle that was not identified until 8 November 2011. He later developed an infection and died on 4 June 2012; the inquest recorded congestive cardiac failure and bronchopneumonia, with the fractured ankle and subsequent infection contributing to his death. Concerns included incomplete Cardex records, inadequate follow-up of incident reports, and insufficient cross-referencing or monitoring of records, which meant his injuries were not identified promptly.
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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 properly complete Cardex records
Wider context from the report “(1) There was evidence provided at the Inquest that showed that the Cardex system used at the home was not being properly completed . Dates, on occasions, appeared to be out of order and important information such where a patient had fallen was not being recorded . Family concerns also did not appear to always be recorded .
” Source location Stanley Bere · 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 Strengthen incident reporting by recording and updating falls, accidents and near misses, with regular management auditing and follow-up.
Verbatim wording from the response “We have tightened up our reporting systems, particularly ensuring all falls, accidents and "near misses" are recorded, and updating on any accident or incident. A more secure system of archiving has been introduced. We have also found a copy of a receipt we asked the coroner's officer to sign when taking the records, as she had no letter with her. I have enclosed a copy for your records. The home manager regularly checks that issues are recorded and followed up in his regular auditing of documents. Staff are aware of the consequences if they do not follow correct procedures. These improvements were put in place immediately following the inquest.” Source location 2014-0339-Response-by-Older-Peoples-Services
Open published response
1 Jul 2014 John Henry ADAMS · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 2
Inaccurate terminology about the cause of procedural injury View source Failure to record suspected trial-related causes in hospital notes View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
John Henry ADAMS · 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
John Henry Adams died following multiple complications of an appropriate cardiac intervention after being recruited to a cardiac trial just before the procedure. Concerns included whether there was sufficient time for informed consent, the suitability and preparedness of the trial operator, and the recording and communication of the trial’s possible relevance to the cardiac tamponade and subsequent death.
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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 Inaccurate terminology about the cause of procedural injury
Wider context from the report “(7) The hospital notes in Brighton, the letter of referral to Kings College Hospital and the report to the Coroner all gave the impression, because of the wording used, that what had happened at the PCI was that the diagonal artery had dissected and this is what is believed to have caused the pericardial effusion and tamponade.
The Consultant Cardiologist is the only person to have used the expression "dissection" to describe the damage to the diagonal artery which occurred during the PCI.
Should more care be taken in terminology? In this case it seems to have lead to a great deal of confusion.
” Source location John Henry ADAMS · 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 record suspected trial-related causes in hospital notes
Wider context from the report “(6) The Hospital notes for Mr. Adams admission on the 30th do not mention the view (apparently formed within an hour or so of surgery), that it was the pacing wires; which was the extra requirement of the Trial; which caused the cardiac tamponade .
Why not? Why was this information effectively concealed?
” Source location John Henry ADAMS · Prevention of Future Deaths report
Open source report
9 Jun 2014 Daniel Joseph McCallum Keane · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Inadequate clinical record keeping View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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AI-generated summary
Daniel Joseph McCallum Keane · 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 Keane was found dead at home after a period in which he had difficulty managing his Type 1 diabetes and was left without active support apart from his family. The cause of death was recorded as ketoacidosis. The reported concerns included a lack of leadership and coordination, no clear post-discharge care plan, ineffective multidisciplinary meetings, and uncertainty about the GP’s role, including the prescribing of citalopram and failure to respond to concerns about Daniel’s wellbeing.
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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 Inadequate clinical record keeping
Wider context from the report “████████ was called to give evidence at the Inquest. He accepted in the course of his evidence that his record keeping was inadequate. He could not say from either his records or his recollection who had arranged for diabetic medication or citalopram to be prescribed on 29th September 2010.
████████ had no recollection or contemporaneous record of a telephone conversation with a neuropsychologist called ████████ on 8th November 2010 in which she said she alerted ████████ to Daniel Keane’s situation, which she described to him and indicated it was very worrying. ████████ asked him to make an urgent referral to the district nurses as she was concerned he was not reliable in managing his insulin himself. ████████ said he could not refer to the district nurses. Despite having been put on alert in this telephone conversation ████████ took no action.
At this time ████████ was in possession of various reports including a Multi-Disciplinary Team Discharge Summary dated 2nd September 2010 that concluded Daniel Keane was at extreme risk to himself and was not a safe option to live by himself without supervision.
2. An investigation of the circumstances in which citalopram was prescribed on 29th September 2010 to establish who deemed this medication necessary, what features of his presentation justified this medication and the follow up action envisaged.
3. An investigation into ████████'s lack of response to the telephone conversation with ████████ on 8th November 2010.
4. Consideration of the role of GP’s generally in relation to the management of Type 1 diabetic patients in the community.
” Source location Daniel Joseph McCallum Keane · Prevention of Future Deaths report
Open source report
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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 Concerns about the practice’s record keeping, prescribing and response should be addressed by the GMC and CQC, which can take action where warranted.
Verbatim wording from the response “I consider that the first three concerns, relating to ████████ should be raised with the General Medical Council (GMC) and the Care Quality Commission (CQC). To this end, my officials contacted your office on 12 June to advise that these actions would be most appropriately addressed by the GMC and CQC. We suggested that you write to both of these organisations for their separate responses to these issues. These organisations have the power to take action where warranted.” Source location 2014-0260-Response-by-Department-of-Health
Open published response
5 Jun 2014 THOMAS PATRICK MAHER · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Unavailability of nursing notes, observation charts and pressure ulcer charts View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
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. 4
Manchester University NHS Foundation Trust
Scan records for deceased patients and patients involved in high-level incidents into the electronic patient record as a priority.
View source
Manchester University NHS Foundation Trust
Implement the Patientrack electronic observation and early-warning-score monitoring system across Trafford Hospital.
View source
Manchester University NHS Foundation Trust
Develop and roll out the Chameleon electronic patient-record system across the Trust in stages.
View source
Manchester University NHS Foundation Trust
Run the Health Records Improvement Programme to address patient-record management risks.
View source See 1 more action
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AI-generated summary
THOMAS PATRICK MAHER · 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
Thomas Patrick Maher fell on a ward at Trafford General Hospital on 3 February 2014 and fractured his acetabulum. The report identified concerns about missing clinical records, assessments and alarm arrangements relating to falls risk, delays and problems in transferring him between hospitals, ward placement, medication administration, notification of next of kin, and the transfer of patient notes. The investigation recorded the medical cause of death as chest sepsis, hospital-acquired pneumonia and a left acetabulum fracture of the hip, with other conditions also listed.
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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 Unavailability of nursing notes, observation charts and pressure ulcer charts
Wider context from the report “1. All the nursing notes, observation charts and pressure ulcer charts for the period 20th December 2013 to 29th January 2014 are missing , and despite a widespread search by the hospital, it has proved impossible to locate them . This had the effect of hampering the High Level Investigation and potentially the inquest itself.
” Source location THOMAS PATRICK MAHER · 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 Scan records for deceased patients and patients involved in high-level incidents into the electronic patient record as a priority.
Verbatim wording from the response “Trafford Hospital acknowledges that the loss of these nursing records is unacceptable. In order to minimise the risk of this issue arising again, a new process has been implemented by the Trafford Medical Records Manager that all records, including nursing charts, for any patient who has died and for any patient involved in a high level incident will be scanned into the electronic patient records (EPR) system as a priority.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
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 Patientrack electronic observation and early-warning-score monitoring system across Trafford Hospital.
Verbatim wording from the response “In the future, the recording of observations will be electronic with the implementation of the Patientrack early warning score monitoring system. The implementation of this new system is planned to commence across Trafford Hospital from the end of October 2014. Once fully installed, observation charts will always be available electronically.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and roll out the Chameleon electronic patient-record system across the Trust in stages.
Verbatim wording from the response “There is a longer term aim that all patient records, including nursing notes and charts, will be electronic across the whole of the Trust using a system called Chameleon. This will minimise the risks that documentation will be lost. The timeframe for this to be complete across the entire Trust is 2018. However, this is being developed and implemented in stages so it is likely that Trafford will be fully electronic before then.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
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 Run the Health Records Improvement Programme to address patient-record management risks.
Verbatim wording from the response “The Trust acknowledges that the management of patient records is a significant risk. The risk is included on the Trust Risk Register and a Health Records Improvement Programme is underway to address the issues. As explained earlier, there is a longer term aim that all patient records, including nursing notes and charts, will be electronic across the whole of the Trust.” Source location 2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Open published response
2 Jun 2014 Denise PRIOR · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Inadequate record-keeping of oxygen levels and prescriptions View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Sussex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
University Hospitals Sussex NHS Foundation Trust
Apply the Trust oxygen-prescribing and monitoring policy in all settings.
View source
University Hospitals Sussex NHS Foundation Trust
Re-audit oxygen-policy use and redistribute the updated Rapid Response report.
View source
University Hospitals Sussex NHS Foundation Trust
Audit compliance with the current drug chart and present outcomes to clinical governance groups.
View source
University Hospitals Sussex NHS Foundation Trust
Obtain an online F1 training package containing oxygen-prescribing content and make completion mandatory during doctors’ first year.
View source
University Hospitals Sussex NHS Foundation Trust
Obtain online medical-gases training for nurses and establish a method for completing it.
View source
University Hospitals Sussex NHS Foundation Trust
Move inspired-oxygen recording from the electronic observation chart to the electronic prescribing screen.
View source
University Hospitals Sussex NHS Foundation Trust
Upgrade PatientTrack to record the oxygen device delivered to patients.
View source
University Hospitals Sussex NHS Foundation Trust
Share the upgraded oxygen-device recording facility with other UK hospitals using PatientTrack.
View source See 5 more actions
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AI-generated summary
Denise PRIOR · 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
Denise Prior died on 6 November 2013 following a cardiac arrest after a fall caused by her underlying medical condition. The report raised serious concerns about record-keeping at St Richards Hospital, including recording and prescribing oxygen and applying the National Early Warning Score system, with a stated risk of future deaths.
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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 Inadequate record-keeping of oxygen levels and prescriptions
Wider context from the report “That there is a risk of other deaths occurring in the future from the inadequacy of record-keeping practices at St Richards Hospital in the recording of oxygen levels and its prescription , and in the application or departure from the ‘NEWS’ system.
” Source location Denise PRIOR · 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 Apply the Trust oxygen-prescribing and monitoring policy in all settings.
Verbatim wording from the response “Action taken
There is a current and very robust Trust policy regarding prescribing and monitoring of oxygen – all requirements to be followed in all settings.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
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 Re-audit oxygen-policy use and redistribute the updated Rapid Response report.
Verbatim wording from the response “There was Rapid Response alert issued by NPSA in 2009. This alerted all NHS organisations to assess and self-implement the issues identified but there is a case for refreshing the message after five years on.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with the current drug chart and present outcomes to clinical governance groups.
Verbatim wording from the response “Compliance with the current drug chart, which was developed in line with oxygen prescribing policy and directs towards the identification of device and O2 saturation target.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain an online F1 training package containing oxygen-prescribing content and make completion mandatory during doctors’ first year.
Verbatim wording from the response “We are going to have access to an online training package (via HEKSS) for F1s – which a respiratory section of which should be included in oxygen prescribing. This should become mandatory training for doctors for completion during the first year.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
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 Obtain online medical-gases training for nurses and establish a method for completing it.
Verbatim wording from the response “We are going to have access to online training packages for nurses in relation to medical gases including oxygen and should ensure that they understand their usefulness and a method to implement their completion.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Move inspired-oxygen recording from the electronic observation chart to the electronic prescribing screen.
Verbatim wording from the response “In contradiction to the evidence given to the Assistant Coroner at the inquest, PatientTrack does have the facility to record inspired oxygen concentration (FiO2) delivered to the patient and this is used within the Trust. The screenshot below is currently taken place on the electronic observation chart, but will move onto the electronic prescribing screen where it is a realtime facility for recording and not describing, hence the opposite gives a realtime assessment of the inspired oxygen.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
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 Upgrade PatientTrack to record the oxygen device delivered to patients.
Verbatim wording from the response “Oxygen concentration for mechanically ventilated patient monitored” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the upgraded oxygen-device recording facility with other UK hospitals using PatientTrack.
Verbatim wording from the response “The team at WSHT are also in the process of upgrading this facility so that the actual oxygen device (e.g. nasal prongs, Venturi, non-invasive ventilation) can also be recorded in Patientrack, and this facility will also be shared with other hospitals in the UK using Patientrack.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
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 PatientTrack appears accessible via desktop computers; intermittency was attributed to uncharged Android handheld devices rather than system unavailability.
Verbatim wording from the response “(3) Problems with intermittency of working of patient track paper as an alternative.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
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 PatientTrack is intended as the normal record, with paper charts reserved for significant information-technology problems.
Verbatim wording from the response “The issue appears to be that the Android handheld devices were not charged, as PatientTrack can be accessed at all times by desktop computers at the nurses station.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
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 current Trust policy robustly governs oxygen prescribing and monitoring, with requirements to be followed in all settings.
Verbatim wording from the response “Matter of concern
(2) Lack of recording of oxygen prescription and concentration and accountability on patient track.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
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 PatientTrack already has, and the Trust uses, a facility to record inspired oxygen concentration delivered to patients.
Verbatim wording from the response “(4) Record of inspired Oxygen concentration on PatientTrack.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.