9 Feb 2026 Ellen Victoria Floyd Taylor · Prevention of Future Deaths report Northumberland
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Concerns raised 1
Failure to consider altered gastric anatomy and investigate potential perforation when complications arise 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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Ellen Victoria Floyd Taylor · 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
Ellen Victoria Floyd Taylor, aged 69, died on 1 July 2025 after a nasogastric tube perforated her small intestine, resulting in acute peritonitis. Her previous gastric bypass surgery and altered anatomy were not known to treating professionals, and the report raises concerns about the lack of guidance and wider NHS risk regarding nasogastric tube insertion in patients with previous gastric surgery.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider altered gastric anatomy and investigate potential perforation when complications arise
Wider context from the report “(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.
On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.
The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially .
(2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery.
The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion.
Previous surgery was not a routine consideration and not included within the nasogastric tube guideline. Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.
Whilst the local NHS Traut have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS Trust nationally and there is a risk future deaths will occur unless action is taken.
” Source location Ellen Victoria Floyd Taylor · Prevention of Future Deaths report
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23 Sep 2025 Tony Buengo Jackson · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to detect iatrogenic injury despite clinical assessment and investigation View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Tony Buengo Jackson · 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
Tony Buengo-Jackson, who had progressive multiple sclerosis and lived in a nursing home, died after a PEG tube inserted on 19 November 2024 passed through his transverse colon, causing bowel perforation, peritonitis and sepsis. The report raises concerns that the injury was not detected until 3 December despite an earlier admission, CT scan and surgical consultation, and that poor records and inadequate Trust governance impeded investigation and learning.
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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 detect iatrogenic injury despite clinical assessment and investigation
Wider context from the report “1. A fatal iatrogenic injury caused to Tony Buengo-Jackson on 19th November 2024 went undetected until 3rd December 2024 , despite admission, CT scan and surgical consult on 24th November 2024 .
” Source location Tony Buengo Jackson · Prevention of Future Deaths 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 Expand Martha’s Rule to all acute inpatient sites.
Verbatim wording from the response “Measures we have taken over the last year include:” Source location Response from Department of Health and Social Care
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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 consultant surgeon’s CT interpretation was a reasonable differential diagnosis given the evidence available at the time.
Verbatim wording from the response “Our review confirmed that the consultant surgeon’s interpretation of the CT scan at that time represented a reasonable differential diagnosis given the available evidence. However, the rationale for this interpretation was not fully documented, limiting retrospective understanding of the decision.” Source location Response from Barts Health NHS Trust
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10 Feb 2023 Celia Sanderson · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of DGH Emergency Department protocols and staff awareness for recognising potential silver trauma cases at arrival View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England
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AI-generated summary
Celia Sanderson · 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
Celia Sanderson was involved in a road traffic collision and died at Wythenshawe Hospital after developing severe injuries, neurological damage and an acute myocardial infarction while awaiting transfer to a major trauma centre. The concerns included delays in triage and clinician review, shortages of senior emergency department and radiology staff, delays in CT scanning and reporting, and insufficient recognition of potential “silver trauma” cases in district general hospitals.
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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 Lack of DGH Emergency Department protocols and staff awareness for recognising potential silver trauma cases at arrival
Wider context from the report “4. The inquest heard evidence from a trauma specialist about the importance of recognising “silver trauma”. There was recognition amongst trauma specialists of the high risk of significant trauma amongst elderly patients such as Mrs Sanderson even from what could appear to be relatively minor incidents. As a consequence major trauma centres generally had developed protocols that assisted staff at triage to pick up such cases and prioritise them and set a low threshold for an early CT scan . Such protocols were not generally in force in DGH settings . The evidence was that there needed to be steps taken to increase awareness amongst DGH ED staff to pick up these potential silver trauma cases on arrival in order to expedite discussion with and transfer to a trauma centre and increase the chances of survival.
” Source location Celia Sanderson · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHSE and local integrated care bodies are responsible for addressing the concerns about treatment at Wythenshawe Hospital.
Verbatim wording from the response “Your report raises concerns about the treatment provided at Wythenshawe Hospital, Manchester University NHS Foundation Trust. I understand that NHS England (NHSE) have written to you to address these concerns, including information from Greater Manchester Integrated Care and the Integrated Care Board on the action taken locally. This includes NHS Greater Manchester’s action plan to respond to urgent and emergency care demand pressures, as well as their Major Trauma Network. This network provides care to patients who have sustained major trauma injuries; partners work collaboratively to ensure trauma is recognised and treated appropriately. Learning from the investigation into Ms Sanderson’s death has been used to improve practice across the network.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Greater Manchester Integrated Care provides the relevant services, while its Integrated Care Board decides commissioned health services.
Verbatim wording from the response “In order to be able to respond to your Report, NHS England has engaged with Greater Manchester Integrated Care (NHS GM) who is the provider of the healthcare services in question, and the Integrated Care Board (ICB) who is responsible for making decisions about commissioned health services across Greater Manchester NHS England’s response to your Report is based on our informed discussions with these two organisations.” Source location Response from NHS England
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1 Feb 2021 BETTY ANNIE TADMAN · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 2
Failure to consider fracture or internal bleeding during continued deterioration View source Failure to consider potential fracture injury View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Medway 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. 5
Medway NHS Foundation Trust
Deliver staff teaching and simulated training on evidence-based trauma care for elderly patients.
View source
Medway NHS Foundation Trust
Resume the suspended staff teaching and simulated training programme on elderly trauma care.
View source
Medway NHS Foundation Trust
Implement ED silver trauma screening for frail patients with low-energy trauma, including senior-clinician assessment where red flags require escalation.
View source
Medway NHS Foundation Trust
Adopt the London Major Trauma System elderly-trauma screening and triage pathway prompting immediate senior-doctor assessment.
View source
Medway NHS Foundation Trust
Provide a specialist-nurse front-door team to assess frail elderly patients arriving in ED and expedite transfer, escalation or discharge.
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BETTY ANNIE TADMAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Betty Annie Tadman died after an unwitnessed fall at home caused a pelvic fracture with extensive local haemorrhage. She was treated for suspected urosepsis and deep vein thrombosis, but no imaging was conducted despite signs of possible injury, and the pelvic fracture and internal bleeding were not diagnosed. Concerns were also raised that the Trust did not investigate the death or review it through its morbidity and mortality processes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider fracture or internal bleeding during continued deterioration
Wider context from the report “5. There was no consideration of potential fracture or internal bleeding in the presence of dropping of haemoglobin and continued deterioration.
” Source location BETTY ANNIE TADMAN · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider potential fracture injury
Wider context from the report “2. Evidence was heard at the inquest that ambulance crew noted and handed over Mrs Tadman’s left leg was rotated but not shortened. Mrs Tadman could not stand or mobilise to use the commode in hospital. No consideration was given to a potential fracture injury.
” Source location BETTY ANNIE TADMAN · 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 Deliver staff teaching and simulated training on evidence-based trauma care for elderly patients.
Verbatim wording from the response “2.2. Prior to the Covid pandemic, extensive staff teaching and training had already been undertaken on improving trauma care of the elderly with a focus on the emerging evidence-based pathway of “silver trauma” care. This training programme, which included simulated exercises, is currently suspended but will be resumed shortly.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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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 Resume the suspended staff teaching and simulated training programme on elderly trauma care.
Verbatim wording from the response “2.2. Prior to the Covid pandemic, extensive staff teaching and training had already been undertaken on improving trauma care of the elderly with a focus on the emerging evidence-based pathway of “silver trauma” care. This training programme, which included simulated exercises, is currently suspended but will be resumed shortly.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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 ED silver trauma screening for frail patients with low-energy trauma, including senior-clinician assessment where red flags require escalation.
Verbatim wording from the response “2.3. The Trust is committed to implementing the “silver trauma” screening system in ED for frail patients presenting with ‘low energy’ trauma with an assessment led by a senior clinician (ST 4 +) if there are any red flags signs for escalation.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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 Adopt the London Major Trauma System elderly-trauma screening and triage pathway prompting immediate senior-doctor assessment.
Verbatim wording from the response “2.5. The Trust plans to adopt the London Major Trauma System; Management of Elderly Major Trauma Patients – Second Edition whereby trauma units use an effective screening triage tool on elderly patients who self-present or arrive by ambulance and this prompts an immediate senior doctor (ST4+ level ) review for assessment. Since November 2018, we have already introduced a “front door” team of specialist nurses to assess elderly frail patients upon arrival in ED to expedite their transfer to the ward or escalate for medical advice or discharge as appropriate.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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 Provide a specialist-nurse front-door team to assess frail elderly patients arriving in ED and expedite transfer, escalation or discharge.
Verbatim wording from the response “2.5. The Trust plans to adopt the London Major Trauma System; Management of Elderly Major Trauma Patients – Second Edition whereby trauma units use an effective screening triage tool on elderly patients who self-present or arrive by ambulance and this prompts an immediate senior doctor (ST4+ level ) review for assessment. Since November 2018, we have already introduced a “front door” team of specialist nurses to assess elderly frail patients upon arrival in ED to expedite their transfer to the ward or escalate for medical advice or discharge as appropriate.” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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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 ambulance record documented a shortened leg without rotation, contrary to the inquest evidence.
Verbatim wording from the response “1.2. Evidence was heard at the Inquest that ambulance crew noted and handed over that Mrs Tadman’s left leg was rotated but not shortened. Mrs Tadman could not stand or mobilise to use the commode in hospital. No consideration was given to a potential fracture injury. (The Trust wishes to point out that in fact the ambulance record documented shortening but no rotation)” Source location 2021-0023-Response-from-Medway-Maritime-Hospital-Redacted
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5 Sep 2019 Tillie SPENCER-ADAMS · Prevention of Future Deaths report Hertfordshire
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Concerns raised 1
Failure to identify serious injuries following road traffic collisions View source
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AI-generated summary
Tillie SPENCER-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
Tillie Spencer-Adams was found unresponsive in her mother's bed on 18 June 2018 and could not be resuscitated. The medical cause of death was unascertained, with the inquest concluding Sudden Unexpected Death in Infancy. The report identified concern that injuries potentially sustained in a road traffic collision, including fractures and head injuries, may have been overlooked when she attended hospital on 4 May 2018.
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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 identify serious injuries following road traffic collisions
Wider context from the report “(1) On the 4/5/18 the deceased attended the Lister Hospital following a road traffic collision in which she is likely to have suffered serious injuries (fractures and head injuries) which appear to have been overlooked .
” Source location Tillie SPENCER-ADAMS · Prevention of Future Deaths 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 Review the care provided on 4 May 2018.
Verbatim wording from the response “The contents of your letter were of grave concern to me and therefore I asked ████████ Clinical Director for Paediatrics, to review the care provided when Tillie attended on 4th May 2018.” Source location 2019-0356-Response-by-East-and-North-Hertfordshire-NHS-Trust
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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 Clinical findings did not require head or forearm imaging; assessment and national guidance supported no further investigation.
Verbatim wording from the response “Whilst the triage nurse in ED noted a red mark on Tillie’s head, this was not observed by either the Paediatric doctors who reviewed her, nor any of the Paediatric nurses. In addition, Tillie did not exhibit any red-flag symptoms indicative of a head injury. Thus, in line with NICE Guidance, there was no indication to perform a CT head scan. Equally there were no external signs of any injury to her right forearm, nor did Tillie appear to be in any discomfort whilst in ED or the Paediatric unit. She did not require any analgesia and the medical records indicate that she was settled throughout.” Source location 2019-0356-Response-by-East-and-North-Hertfordshire-NHS-Trust
Open published response
Concerns raised 1
Failure to undertake further imaging in borderline presentations of significant head injury View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
John Robert Maltby Worthington · 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 Robert Maltby Worthington fell down stairs in late March or early April 2017 and was treated for a head injury, with back and neck pain noted. He was later found to have spinal and rib fractures and pneumonia, and died in hospital on 29 June 2017 from bronchopneumonia, osteomyelitis of the spine and traumatic spinal fracture. The concerns included not undertaking further imaging after the initial fall and not recording a full set of observations or conducting further investigations when he later saw his GP with persistent back pain.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to undertake further imaging in borderline presentations of significant head injury
Wider context from the report “(1) The deceased attended A&E on the 4th April 2017.He had a very significant head injury 10 cm long requiring 15 stitches and exposing the skull. He had fallen downstairs. He gave a history of a fall from 4 steps. He complained of back and neck pain. Examination of the spine did not reveal any tenderness and other observations were within normal parameters. Further investigations were considered unnecessary and the NICE guidelines were considered. . The deceased’s presenting complaint appeared to fall within a grey area/borderline decision warranting further investigation by way of x-ray/scan. A decision was made not to do this. He later died from injuries sustained in that fall. It is understood that nationally work may be underway to reduce the threshold in such borderline cases. It may be of benefit to future patients for this matter to be further considered.
” Source location John Robert Maltby Worthington · Prevention of Future Deaths 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 No further investigations were considered necessary because there were no clinical signs indicating a need at the time.
Verbatim wording from the response “████████ felt that she provided a high standard of care to Dr Worthington at this consultation; having insisted that he attended the Practice for a face to face consultation and the carrying out a detailed assessment. ████████ clinical opinion at the time was that there were no untoward signs of head injury and there were no clinical signs at the time to suggest that any further investigations were needed. ████████ had listened to Dr Worthington’s chest and concluded that the lungs were clear.” Source location 2018-0204-Response-by-MDDUS
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29 Mar 2018 Mr Frank Hayward · Prevention of Future Deaths report Black Country
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Concerns raised 1
Failure to correctly assess and diagnose injuries in the Emergency Department View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Sandwell and West Birmingham Hospitals NHS 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
Sandwell and West Birmingham Hospitals NHS Trust
Revise the head-injury guideline to align with NICE guidance and add head-and-neck imaging prompts to the proforma.
View source
Sandwell and West Birmingham Hospitals NHS Trust
Require all clinicians to use the head-injury proforma for hospital falls and Emergency Department presentations.
View source
Sandwell and West Birmingham Hospitals NHS Trust
Adopt the approved head-injury guideline within one month and address identified implementation challenges.
View source
Sandwell and West Birmingham Hospitals NHS Trust
Monitor implementation of the approved head-injury guideline, including imaging, observation duration, specialist referrals and follow-through of requested actions.
View source See 1 more action
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AI-generated summary
Mr Frank Hayward · 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 Hayward fell at home on 12 November 2017, sustaining an odontoid peg fracture and subdural haemorrhage, and died on 10 December 2017 after his condition declined. The concerns included failures to correctly assess and diagnose his injuries, delays in Trauma and Orthopaedics review and urgent CT scanning, and poor systems and communication in obtaining a cervical collar.
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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 correctly assess and diagnose injuries in the Emergency Department
Wider context from the report “1. Evidence emerged during the inquest that there were failures to correctly assess and diagnose his injuries in the Emergency Department and there were missed opportunities to have him reviewed by Trauma and Orthopaedics team sooner.
” Source location Mr Frank Hayward · Prevention of Future Deaths 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 Revise the head-injury guideline to align with NICE guidance and add head-and-neck imaging prompts to the proforma.
Verbatim wording from the response “The guideline used by clinicians to inform diagnostic testing and treatment of Head Injuries has been revised in line with the latest National Institute for Excellence (NICE) Clinical Guideline (CG176). Our guideline includes an algorithm of when to image the spine and the head injury proforma now includes a checklist for both head and neck imaging as a further prompt. This proforma was traditionally only used in the Emergency Department (ED), but will now be a requirement for all clinicians to use on any patient who sustains a fall in hospital as well as those who present to the ED. Equally the guideline will apply to anyone who has sustained a head injury, providing consistency with referrals and observations.” Source location Frank-Hayward-Response
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 Require all clinicians to use the head-injury proforma for hospital falls and Emergency Department presentations.
Verbatim wording from the response “The guideline used by clinicians to inform diagnostic testing and treatment of Head Injuries has been revised in line with the latest National Institute for Excellence (NICE) Clinical Guideline (CG176). Our guideline includes an algorithm of when to image the spine and the head injury proforma now includes a checklist for both head and neck imaging as a further prompt. This proforma was traditionally only used in the Emergency Department (ED), but will now be a requirement for all clinicians to use on any patient who sustains a fall in hospital as well as those who present to the ED. Equally the guideline will apply to anyone who has sustained a head injury, providing consistency with referrals and observations.” Source location Frank-Hayward-Response
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 Adopt the approved head-injury guideline within one month and address identified implementation challenges.
Verbatim wording from the response “The revised draft guideline was recently shared at our Quality Improvement Half Days on 16th May, asking teams and specialties to take note of the requirements of the guideline and to highlight any challenges they see in implementing the changes and providing any solutions. The output of everyone’s sessions are being collated and shared with the Medical Director, Dr David Carruthers. We clearly need a guideline that provides for patients such as Mr Hayward, but need to balance this with any changes required to services to ensure this provision is possible. Dr Carruthers will ensure that the approved guideline is adopted within the next month, with plans to meet any specific challenges.” Source location Frank-Hayward-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 Monitor implementation of the approved head-injury guideline, including imaging, observation duration, specialist referrals and follow-through of requested actions.
Verbatim wording from the response “We will monitor the use of the approved Head Injury guideline following a period of implementation, but in particular we will be ensuring that:” Source location Frank-Hayward-Response
Open published response
31 Oct 2017 William Henry BERGMAN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2
Failure to obtain detailed symptom information after head injury View source Failure to consider the potential for serious consequences from head injury in vulnerable older people View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Barts Health NHS Trust
Introduce a formal trust-wide policy for managing head injury in patients and staff.
View source
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AI-generated summary
William Henry BERGMAN · 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
William Henry Bergman, who had vascular dementia, was admitted to hospital with pneumonia and died after sustaining a forehead impact while being changed on 19 December 2016. He was later found to have a subdural haematoma and massive intracranial bleed. The principal concern was that the staff nurse treated the injury as minor without requesting immediate observations or medical review, and did not change the management plan when a bruise and lump were later noted.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to obtain detailed symptom information after head injury
Wider context from the report “The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine.
Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick .
She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review.
She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence.
When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan.
She completed a Datix report only the following day, after Mr Bergman’s death.
The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing.
The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way.
” Source location William Henry BERGMAN · 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 consider the potential for serious consequences from head injury in vulnerable older people
Wider context from the report “The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine .
Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick.
She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review.
She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence .
When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan.
She completed a Datix report only the following day, after Mr Bergman’s death.
The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing.
The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences , then others may behave in the same way.
” Source location William Henry BERGMAN · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a formal trust-wide policy for managing head injury in patients and staff.
Verbatim wording from the response “Certain preventative measures have already been taken. Since October 2017 new post management of head injury guidance and a training package has been rolled out within the Royal London Hospital Older Peoples Service wards with other inpatient areas to follow. The guidance ‘Observation of patients’ with head injury in hospital’ was developed as an interim measure prior to the role out of a more formal and trust wide policy for the management of head injury (patients and staff) next year when this is completed (March 2018).” Source location 2017-0343-Barts-NHS-Trust
Open published response
29 Aug 2017 BERYL MARGARET ELIZABETH GOODE · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1
Failure of night shift staff to consider and exclude possible head injury in residents with confusion View source
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
BERYL MARGARET ELIZABETH GOODE · 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
Beryl Margaret Elizabeth Goode fell while trying to use a commode, later became confused, and was subsequently found on the floor with an obvious head injury. She was taken to hospital and died on 2 May 2017. The principal concerns were that staff did not consider head injury as a possible cause of her confusion and lacked training to identify or exclude it, including when a resident denied injury.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of night shift staff to consider and exclude possible head injury in residents with confusion
Wider context from the report “(1) At no point did the night shift staff consider that a head injury could have been the cause of the deceased’s confusion.
(2) It is accepted that the night shift are not medically trained . However, that makes it all the more important that they are aware of the possibility of a head injury to the residents, even in circumstances where the resident denies an injury.
(3) It is also accepted that the deceased may not actually have had a head injury from the first fall. Nevertheless, without training, the staff were not able to exclude a head injury.
(4) It is also accepted that calling the emergency services some 2 hours earlier would not have prevented her death if she had sustained a head injury in the first fall. However, in certain scenarios, residents in the future may have their lives saved if head injury is considered as a possible diagnosis.
” Source location BERYL MARGARET ELIZABETH GOODE · Prevention of Future Deaths report
Open source report
3 Mar 2017 Joan RIMMER · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Failure to take physiological readings when assessing physiological response to fracture View source
This report raised 1 other concern. 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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Joan RIMMER · Prevention of Future Deaths report
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Report summary
Joan Rimmer, who had dementia and lived in a residential home, suffered an unwitnessed fall on 28 November 2016 and was later diagnosed with a right hip fracture. She underwent surgery but subsequently stopped eating and drinking and died on 16 January 2017. The court was concerned that the community matron assessed her without taking physiological readings and wrongly judged that she had refused an X-ray, contributing in part to a two-week delay in diagnosing the fracture.
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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 take physiological readings when assessing physiological response to fracture
Wider context from the report “Though there was no evidence that Mrs Rimmer’s death could have been avoided by earlier diagnosis of her fractured hip – the court is concerned that the Community Matron employed by Liverpool Community Health assessed her physiological response to a fracture without taking any physiological readings and further adjudged her to refuse to be x-rayed when a carer witness who was present has explained that the extent of her dementia on the 29th November was so severe she would not understand sufficient to give consent. This in part led to a two week delay before her hip fracture was diagnosed. In another case such standards of nursing could result in an avoidable death not being prevented.
” Source location Joan RIMMER · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.