Recurring concern

Failure to provide timely medical review of admitted patients

First to latest report 4 Oct 2013 — 17 Jun 2025

Reports that mention this concern
24
Times this concern has been raised
27
Stated actions linked to this concern
35

What this concern includes

Includes failures of the inpatient medical-review process involving absent, delayed or insufficiently timely review of admitted or transferred patients, including review prompted by clinical observations, deterioration, presenting symptoms or a request from ward staff.

What is not included
  • Excludes delays limited to consultant review where the broader medical-review process is not deficient.
  • Excludes nursing observations, monitoring or escalation failures when no failure to provide medical review is identified.
  • Excludes generic staffing, documentation, communication or handover deficiencies unless they directly result in absent or delayed medical review of an admitted patient.
  • Excludes outpatient, community or non-inpatient clinical reviews.

Reports and published responses 24 reports

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

  1. Brighton and Hove

    AI-generated summary

    Kalma RAM-HENMAN · 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

    Kalma RAM-HENMAN died on 7 June 2018 after presenting to A&E in a precarious state and later being found to have a perforated gastric ulcer. The report identified concerns about incomplete fluid monitoring, failure to administer prescribed potassium and sufficient intravenous fluids, missed ECG abnormalities, inadequate repeat blood testing, and delays in responding to her deterioration and providing planned treatment.

    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 provide clinical review and monitoring after ward transfer

    Wider context from the report

    “(6) It may be that her transfer from A&E to Bristol Ward at around 5.30 – 6.30pm on the afternoon of the 6th June (a Thursday) coincided with a time of hiatus on the ward but there should not have been an assumption that she should simply be put in a bed and left until the morning ward round and as I say it seems there was an opportunity missed when she deteriorated in the night and a doctor was asked to see her. ”

    Source location

    Kalma RAM-HENMAN · 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

    Implement separate Acute Medicine Consultant cover for telephone calls while another consultant sees requested patients.

    Verbatim wording from the response

    “Finally, ████████, Consultant in Acute Medicine and Clinical Lead for Ambulatory Care, has implemented a new system whereby an Acute Medicine Consultant will cover telephone calls whilst another Acute Medicine Consultant sees patients when requested. This will ensure that the Consultant seeing patients is released from answering calls and will allow more time for review and follow up of clinical plans.”

    Source location

    2018-0306-Response-by-Brighton-and-Sussex-University-NHS-Trust
    Page 2 · response
    Published 17 February 2019

    Open published response

  2. Norfolk

    AI-generated summary

    KIRSTY ELIZABETH TOLLEY · 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

    Kirsty Elizabeth Tolley had several health problems and was admitted to Queen Elizabeth Hospital with severe anaemia and a high temperature. She was later found unresponsive in bed on 19 November 2017 and was declared dead despite resuscitation. Concerns included blood tests not being carried out daily as required, incomplete Early Warning Score monitoring, and a lack of documented escalation or additional observations when scores reached 3; the medical cause of death was unascertained.

    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 EWS scores of 3 for medical review and increased observations

    Wider context from the report

    “(3) Evidence was heard that if EWS reaches 3, then this should be escalated to a doctor who should review the patient and set a plan. Observations should be increased to 4 times per hour with further review. The EWS reached 3 on 4 occasions (including the occasion when the EWS was not completed in the records – 17 February) and there is no evidence that any additional action was taken. In particular on the 17 February no observations/EWS for over 17 hours. ”

    Source location

    KIRSTY ELIZABETH TOLLEY · 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

    Provide staff with support to understand and use the current escalation system.

    Verbatim wording from the response

    “The staff, both nursing and medical, working in that clinical area have received support to ensure that they understand and are able to use the current escalation system.”

    Source location

    2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
    Page 2 · response
    Published 1 July 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

    Implement NEWS2 with new documentation, training and escalation procedures, supported by communications and a November 2018 go-live.

    Verbatim wording from the response

    “The Trust has therefore decided to bring forward plans to adopt the National Early Warning system (NEWS2) that is mandated across the NHS from April 2019 and will implement this on November 1st 2018.”

    Source location

    2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
    Page 2 · response
    Published 1 July 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

    Appoint a NEWS2 Champion.

    Verbatim wording from the response

    “May 16 Appointment of NEWS2 Champion”

    Source location

    2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
    Page 2 · response
    Published 1 July 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

    Conduct ongoing audits of NEWS2 documentation and escalation.

    Verbatim wording from the response

    “This will be followed by an ongoing audit to ensure appropriate documentation and audit of escalation.”

    Source location

    2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
    Page 2 · response
    Published 1 July 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

    Widespread retraining on older escalation procedures will not occur before NEWS2 implementation because it could cause confusion.

    Verbatim wording from the response

    “The Trust has therefore decided to bring forward plans to adopt the National Early Warning system (NEWS2) that is mandated across the NHS from April 2019 and will implement this on November 1st 2018.”

    Source location

    2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
    Page 2 · response
    Published 1 July 2018

    Open published response

  3. Blackpool and the Fylde

    AI-generated summary

    Barry THOMPSON · 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

    Barry Thompson, an insulin-dependent diabetic, died on 27 February 2016 while a patient on the Acute Medical Unit, after being admitted with sepsis from diabetic foot ulcers and hyperglycaemia. The report identified concerns about failure to provide insulin, fluids, adequate monitoring, antibiotics and medical review, as well as inaccurate and incomplete records and ineffective information sharing during transfer between departments.

    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 provide medical review on the acute medical unit

    Wider context from the report

    “(3) Monitoring patients’ basic needs. There was difficulty encountered giving Mr Thompson saline by way of a drip. He was given an infusion of 1 litre over 4 hours at 17.30. At 23.00 it was found that the original cannula had become detached but the remaining fluid in the sac was 700mls. Mr Thompson’s bed was wet with saline fluid. He did not therefore receive the intended dose. He was not given a further injection of antibiotics 6 hours after the first nor was he written up for it. He was not given insulin. He does not appear to have been given any food whilst a patient or adequate fluid balance charts maintained. He was not seen by a doctor on the AMU. He was on a range of medication on admission to hospital for co-morbidities. The importance of this or otherwise was not assessed by staff. ”

    Source location

    Barry THOMPSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. West Sussex

    AI-generated summary

    Jean Stockley · 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

    Jean Stockley was admitted after an unwitnessed fall down 13 stairs that caused spinal fractures. Her respiratory condition later deteriorated, leading to respiratory failure, intensive care treatment and her death on 20 April 2015. Concerns included failure to review her after a significant NEWS score increase, uncertainty about which doctor should be contacted, reluctance to escalate concerns to senior doctors, and possible benefits of automated NEWS monitoring.

    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 review patients after acute NEWS score deterioration

    Wider context from the report

    “1. On 9 April, Mrs Stockley's respiratory condition was clearly deteriorating necessitating critical care review who recommended careful and consistent observation of principally her oxygen saturation levels. The NEWS score was a vital tool to alert clinical staff to an acute change yet despite the fact the score went from 4 to 8, the junior doctor did not review the patient. I heard evidence from nursing staff that the doctor felt the patient may simply have been anxious. This suggests a potential training need for doctors and/or nurses. ”

    Source location

    Jean Stockley · 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

    Adopt SBAR documentation and a dedicated form for recording critical telephone conversations in patient health records.

    Verbatim wording from the response

    “1. I regret that the documentation arising from the nurse’s call to the doctor after the NEWS score had risen was so brief, and that neither the doctor nor the nurse concerned could recall this telephone conversation at all. The ward has since adopted a protocol known as SBAR (Situation / Background/Assessment/Recommendation), which includes documentation. This helps staff (especially nurses) to frame critical conversations raising concern about their patient, and has been shown to improve communication and patient safety. A special form is used to prepare for and record such telephone conversations, and is then placed in the patient’s health records as a record of the call. I was disappointed to learn that on this occasion the doctor had apparently not visited the ward when he was notified of the sudden rise in Mrs Stockley’s NEWS score.”

    Source location

    2016-0286-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 12 August 2016

    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

    Provide a 24-hour Critical Care Outreach Team service at Princess Royal Hospital to support deteriorating patients.

    Verbatim wording from the response

    “2. Since April 2015, there have been several changes at the Princess Royal Hospital. The Critical Care Outreach Team, to whom you refer, implemented a 24 hour service on the site from June 2015, so are readily available to support and advise on the care of any patient whose condition is deteriorating. A revised NEWS policy has been introduced but it is recognised that some flexibility is required to ensure that contact is made with the member of staff who is most likely to be able to offer timely assistance to the patient. At night, there is no orthopaedic registrar present on the Princess Royal Hospital site, and the critical care and medical registrars who are on site are often better placed to assess the immediate needs of a patient whose condition has unexpectedly changed.”

    Source location

    2016-0286-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 12 August 2016

    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 a revised NEWS policy allowing contact with the staff member best placed to provide timely assistance.

    Verbatim wording from the response

    “2. Since April 2015, there have been several changes at the Princess Royal Hospital. The Critical Care Outreach Team, to whom you refer, implemented a 24 hour service on the site from June 2015, so are readily available to support and advise on the care of any patient whose condition is deteriorating. A revised NEWS policy has been introduced but it is recognised that some flexibility is required to ensure that contact is made with the member of staff who is most likely to be able to offer timely assistance to the patient. At night, there is no orthopaedic registrar present on the Princess Royal Hospital site, and the critical care and medical registrars who are on site are often better placed to assess the immediate needs of a patient whose condition has unexpectedly changed.”

    Source location

    2016-0286-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 12 August 2016

    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

    Remind Twineham ward nursing staff to escalate patient concerns to the nurse in charge.

    Verbatim wording from the response

    “3. Nursing staff on Twineham ward have been reminded that rather than simply handing over to the nurse who will be taking over direct care of a patient on the next shift, any concern about a patient should be drawn to the attention of the nurse in charge. Since June 2016, a senior nurse (band 6) has been rostered to be on duty on the ward throughout the 24 hour period. This person is trained to provide advice, support and clinical guidance to other nurses, including ensuring that appropriate assistance is obtained in the event of a patient deteriorating. It is also the responsibility of the Band 6 nurse to contact a more senior member of the medical team if there is cause for concern arising from advice received from the junior doctor first contacted.”

    Source location

    2016-0286-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 12 August 2016

    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

    Roster a trained senior Band 6 nurse on Twineham ward throughout the 24-hour period to provide guidance and support escalation.

    Verbatim wording from the response

    “3. Nursing staff on Twineham ward have been reminded that rather than simply handing over to the nurse who will be taking over direct care of a patient on the next shift, any concern about a patient should be drawn to the attention of the nurse in charge. Since June 2016, a senior nurse (band 6) has been rostered to be on duty on the ward throughout the 24 hour period. This person is trained to provide advice, support and clinical guidance to other nurses, including ensuring that appropriate assistance is obtained in the event of a patient deteriorating. It is also the responsibility of the Band 6 nurse to contact a more senior member of the medical team if there is cause for concern arising from advice received from the junior doctor first contacted.”

    Source location

    2016-0286-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 12 August 2016

    Open published response

  5. West Yorkshire (Western)

    AI-generated summary

    Ruth Hilda Smith · Prevention of Future Deaths report

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

    Report summary

    Ruth Hilda Smith died on 16 April 2014 at Huddersfield Royal Infirmary after developing a haemothorax following insertion of a central venous line, with sepsis, altered liver function and pneumonia also recorded as causes. Concerns included delays in medical review, inadequate nursing observations, and poor nursing and medical record keeping during the evening of 15 April and early hours of 16 April 2014.

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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 arrange follow-up medical review after a fluid challenge

    Wider context from the report

    “Medical Care A doctor attended at 18.40 upon Mrs Smith but did not make a full record within the medical records. Nursing staff requested a doctor review at 22.30 hours. No doctor attended until 00.30 hours. When a doctor did attend a fluid challenge was implemented. The doctor did not return to review Mrs Smith or put in place arrangements for another doctor to review. At 2.00 hours an FY2 doctor attended following a request by nursing staff. The FY2 doctor determined that Mrs Smith’s bloods and blood gases should be checked. I heard evidence that nursing staff advised the FY2 doctor that Mrs Smith needed more senior medical review by a registrar. The FY2 made no entries within Mrs Smith’s medical records. I have the following concerns: 1. The 2 hour time lapse between a request for a doctor review and a doctor attending upon Mrs.Smith. 2. No review was put in place following the implementation of the fluid challenge. 3. The standard of record keeping and lack of records being made by the doctors who attended up Mrs. Smith on the evening of the 15th April and early hours of the 16th April up until the Registrar’s involvement at 03.25 a.m. on the 16th April. ”

    Source location

    Ruth Hilda Smith · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. Brighton and Hove

    AI-generated summary

    MR. ANTHONY GEERTS · 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. Anthony Geerts sustained a fractured neck of femur, underwent surgery and was transferred for rehabilitation before being moved to a nursing home. He later returned to hospital with hospital-acquired pneumonia and a possible urinary tract infection, and died on 21 November 2014. The concerns included inadequate rehabilitation, incomplete records and monitoring, poor communication and discharge planning, and failures in managing his continence, fluid restriction and possible chest infection; the inquest concluded that neglect at Princess Royal Hospital contributed to his 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

    Failure to provide senior review and follow up suspected infection

    Wider context from the report

    “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly. In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for. His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as (a) There was insufficient physiotherapy staff to do so and (b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th. Neither Mr. GEERTS nor his family were involved in this decision. Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th. Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio. For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection. No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st. Specifically at Princess Royal Hospital: • Notes not completed. • No nursing notes and no NEWS for 10th or 11th • Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded. • No plan for physiotherapy • No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented. • No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented. • No referral of lack of urinary continence. Therefore no plan regarding this. • Failed Trial without catheter on 3rd November 2014. • Bowel monitoring chart not complete • Discharge planning non-existent or inadequate • Communication with patient and family virtually non-existent • No senior review from 4th November 2014; possibility of chest infection not followed up. • Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction. • Discharge lounge information incorrect. ”

    Source location

    MR. ANTHONY GEERTS · 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

    Strengthen senior medical review requirements, including consultant reviews, daily review of sick patients, junior attendance and documentation of discussions.

    Verbatim wording from the response

    “h) review of senior medical input on Twineham ward. The Clinical Director for the musculoskeletal service has emphasized that every patient on Twineham ward should normally be seen by a consultant orthopaedic surgeon or orthogeriatrician at least four times a week (including one day at the weekend), including a conversation with the patient and review of their progress with them. Any patient who is sick should be seen daily by a consultant. The junior medical staff have been reminded that they must attend with the consultant, and should record every such discussion in the notes, if the consultant does not do this themselves”

    Source location

    2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 24 June 2015

    Open published response

  7. Brighton and Hove

    AI-generated summary

    Mrs. Evelyn KENNEDY · Prevention of Future Deaths report

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

    Report summary

    Mrs. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

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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 senior clinical review

    Wider context from the report

    “(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”

    Source location

    Mrs. Evelyn KENNEDY · 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

    Increase permanent Acute Medical Unit staffing, including matron input, an additional senior nurse and a support assistant role.

    Verbatim wording from the response

    “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:”

    Source location

    2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 7 May 2015

    Open published response

  8. London (East)

    AI-generated summary

    Iana-Liza Chervonenko · 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

    Iana-Liza Chervonenko was delivered by emergency caesarean section after delays associated with a pathological CTG, heavy workload, poor communication and clinical decision-making on the labour ward. She was born at 02.30 with no heart rate or spontaneous respiration and died at twenty-four hours of age from hypoxic-ischaemic encephalopathy caused by intra-partum asphyxia. Concerns included inadequate medical cover, deficient documentation and communication, and the absence of a system to notify the treating team when theatre became available.

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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 obtaining timely medical review of concerning or pathological CTG traces

    Wider context from the report

    “1. The Labour Ward was very busy on the night of 7/8th March 2014. The levels of activity on the ward resulted in the following: • A delay in obtaining a medical review to the concerning CTG trace. • A period of 40 minutes before a medical review, following the consultant noting a pathological CTG trace. • Incorrect documentation in relation to the grading of the caesarean section. • Due to the activity on the Labour Ward the obstetric registrar was not able to fully record his assessments of the patient. • The obstetric registrar confirmed that he did not speak to the anaesthetist about the type of anaesthesia to be used due to him being busy with other patients. 2. ████████ had concerning risk factors of reduced foetal movements and a pathological CTG trace. There were no reassuring reasons for the changes in fetal heart rate. A pathological CTG in an antenatal patient with a history of reduced foetal movements should result in a Grade 1 caesarean section. She should have been delivered by 00.40. The theatre is likely to have been free by 00.22. There was however no communication with the treating team of the availability of theatre and this was only noted by the labour ward coordinator whilst conducting her general rounds at around 00.40. Had ████████ been taken to theatre at 00.22, the consultant has confirmed that Iana-Liza would have been delivered by 00.40. I am concerned about the level of medical cover on the labour ward. The consultant has confirmed that Queens Hospital Maternity Unit is a very busy unit. The level of activity on the 7/8th March 2014 did result in care being provided which contributed to the death of Iana-Liza. The doctors were under severe pressure due to the amount of work and all of the doctors who gave evidence confirmed that further medical support on the maternity unit would improve the care provided to patients. A safe system of care would include the clear and accurate documentation of clinical reviews and clinical decisions; fully informed and thorough discussions with colleagues about prioritisation; fully informed discussions with anaesthetists in relation to the type of anaesthesia required and clear communication between the medical team and midwifery team. The limited number of doctors available on the ward at the time resulted in deficient communication and documentation. I also heard that there is currently no system in place for theatre staff to proactively notify the treating team when the theatre becomes available. I did hear that it would be possible for the Standard Operating Protocol for theatre to be amended to require the Maternity Care Assistant to notify the treating team as soon as theatre becomes free (where a patient is awaiting theatre). No steps had however been taken to address this at the time of the Inquest. ”

    Source location

    Iana-Liza Chervonenko · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. London (East)

    AI-generated summary

    Mrs Awa Jeng · Prevention of Future Deaths report

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

    Report summary

    Mrs Awa Jeng was admitted after a fall that caused a fractured left hip and underwent surgery. She subsequently required dialysis but was not adequately monitored on the ward, and tests were delayed until her potassium was at a life-threatening level. She deteriorated, suffered cardiac arrest during intubation, and could not be resuscitated; the inquest concluded that inadequate monitoring and delayed haemofiltration contributed to her 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

    Failure to provide medical review

    Wider context from the report

    “5. Mrs Jeng was also not monitored appropriately on the ward on the evening of 19 December. There was no medical review and insufficient nursing observations. ”

    Source location

    Mrs Awa Jeng · 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

    Improve participation by all on-call teams in refreshed hospital-at-night meetings to review patients flagged as at risk.

    Verbatim wording from the response

    “During Stepping into the Future Programme (a pan-London NHS initiative to ensure that patient experience and safety is optimal) Newham University Hospital has refreshed the hospital at night meeting and work is under way to improve participation by all on-call teams at night to review and discuss patients flagged as at risk at the start of the shift. This includes the introduction of afternoon safety huddles which are open to all staff and disciplines where issues can be raised and resolved.”

    Source location

    2015-0015-Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 20 January 2015

    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

    Send written and verbal instructions requiring junior doctors to record out-of-hours review needs on the trauma sheet before ending shifts.

    Verbatim wording from the response

    “Instructions verbally and written have been sent to all junior doctors in orthopaedics and orthogeriatrics regarding their responsibilities to add details of any patient requiring review out of hours to the trauma sheet before finishing their shifts.”

    Source location

    2015-0015-Response-by-Barts-Health-NHS-Trust
    Page 3 · response
    Published 20 January 2015

    Open published response

  10. Brighton and Hove

    AI-generated summary

    LINDA ANNE RIGNALL · 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

    Linda Anne Rignall's condition changed on 5 May 2014, but the change was not reported to a doctor and she was not assessed; her condition worsened approximately four hours later without a medical review. The report states that this failure to refer her for assessment resulted in the only available window of opportunity to treat her being lost, raising concern about the Acute Medical Unit's fitness for purpose.

    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 changes in patient condition for timely medical assessment

    Wider context from the report

    “(1) At 17:33 on the 5th May 2014, Linda Rignall's condition changed and this was recorded on the NEWS Observation chart. This change in condition should have been reported to a Doctor on the Acute Medical Unit and she should have been assessed. The position worsened some 4 hours later (the next time observations were performed) and there was still no request for a medical review. From the evidence it was clear to me and I found as you will see from the Conclusion that I recorded that this failure to refer Miss Rignall for assessment resulted in the only window of opportunity available to treat her, being lost. This makes me concerned as to AMU's Fitness for Purpose at the current time. I consider this to be serious. ”

    Source location

    LINDA ANNE RIGNALL · Prevention of Future Deaths report
    Page 1 · 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