8 Jun 2026 Barbara Joan COPE · Prevention of Future Deaths report South Yorkshire (West)
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Concerns raised 1
Delays in following up requested blood tests View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Rotherham 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
the Rotherham NHS Foundation Trust
Flag all abnormal results within MEDITECH.
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the Rotherham NHS Foundation Trust
Introduce and communicate a Trust-wide standard operating procedure for managing investigation results.
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the Rotherham NHS Foundation Trust
Review and update the standard operating procedure for critically abnormal pathology results in clinical areas.
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the Rotherham NHS Foundation Trust
Conduct a Pathology audit of documentation for time-critical results telephoned to clinical areas.
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the Rotherham NHS Foundation Trust
Conduct an additional 50-result audit of documentation and appropriate action for time-critical results.
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the Rotherham NHS Foundation Trust
Develop a Power BI module to monitor acknowledgement of results.
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the Rotherham NHS Foundation Trust
Launch an Urgent and Emergency Care Centre pilot using the alertive bleep system to flag critical blood results.
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the Rotherham NHS Foundation Trust
Include learning from the incident in the Quality Newsletter, focusing on acting upon time-critical blood results.
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AI-generated summary
Barbara Joan COPE · 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
Barbara Joan COPE, a 75-year-old woman, presented to Rotherham Hospital with decreased conscious levels, slurred speech and reduced oral intake, and was later found to have a high paracetamol level. The result was not reviewed or acted upon for approximately 19 hours, delaying time-critical treatment. The principal concerns were failures in communicating and following up abnormal results, reviewing investigations during clinical deterioration, and clearly assigning responsibility for ongoing care.
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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 Delays in following up requested blood tests
Wider context from the report “(3) This patient was transferred from the emergency department to the care of Surgery. A referral was then made for Gastroenterology input, they then requested a blood test for paracetamol levels. This was not followed up for 17 hours . There needs to be clear communication, understanding and record keeping of who is responsible for patient and the ongoing follow up and care in these circumstances.
” Source location Barbara Joan COPE · 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 Flag all abnormal results within MEDITECH.
Verbatim wording from the response “Over the years, the Trust has undertaken a programme of quality improvement work, led by the Deputy Medical Director and Chief Clinical Information Officer to strengthen our responsiveness to abnormal results. This has included ensuring that all abnormal results are flagged within MEDITECH (our electronic patient record). In addition, a Standard Operating Procedure setting out the required actions for managing investigation results was introduced and communicated Trust wide.” Source location Response from Rotherham District General Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce and communicate a Trust-wide standard operating procedure for managing investigation results.
Verbatim wording from the response “Over the years, the Trust has undertaken a programme of quality improvement work, led by the Deputy Medical Director and Chief Clinical Information Officer to strengthen our responsiveness to abnormal results. This has included ensuring that all abnormal results are flagged within MEDITECH (our electronic patient record). In addition, a Standard Operating Procedure setting out the required actions for managing investigation results was introduced and communicated Trust wide.” Source location Response from Rotherham District General Hospitals
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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 and update the standard operating procedure for critically abnormal pathology results in clinical areas.
Verbatim wording from the response “Since Mrs Cope’s death we have reviewed and updated the Standard Operating Procedure for the Management of Critically Abnormal Pathology Results in Clinical Areas and I attach a copy of the same for your reference.” Source location Response from Rotherham District General Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a Pathology audit of documentation for time-critical results telephoned to clinical areas.
Verbatim wording from the response “An audit has been conducted by Pathology to check that the documentation for time critical results telephoned to clinical areas complies with the Standard Operating Procedure with a finding that results audited had been communicated in a timely manner. An additional audit of 50 results is currently underway focusing on whether time critical results have been documented and acted on appropriately. The result of this audit is expected by the end of August 2026.” Source location Response from Rotherham District General Hospitals
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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 Conduct an additional 50-result audit of documentation and appropriate action for time-critical results.
Verbatim wording from the response “An audit has been conducted by Pathology to check that the documentation for time critical results telephoned to clinical areas complies with the Standard Operating Procedure with a finding that results audited had been communicated in a timely manner. An additional audit of 50 results is currently underway focusing on whether time critical results have been documented and acted on appropriately. The result of this audit is expected by the end of August 2026.” Source location Response from Rotherham District General Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a Power BI module to monitor acknowledgement of results.
Verbatim wording from the response “In addition, the Trust has developed a Power BI module to monitor acknowledgement of results which continues to show an improvement in clinicians’ responsiveness to the management of test results.” Source location Response from Rotherham District General Hospitals
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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 Launch an Urgent and Emergency Care Centre pilot using the alertive bleep system to flag critical blood results.
Verbatim wording from the response “I was concerned to hear that Mrs Cope deteriorated overnight, requiring two separate clinical reviews and despite this, her blood results were not reviewed. The Trust has a clear handover process in place whereby medical staff working in hours, handover tasks for follow up to the out of hours team at the face-to-face handover meetings. In addition to this, we will imminently launch a pilot within our Urgent and Emergency Care Centre of the use of the ‘alertive bleep’ system which flags critical blood results on the bleep system.” Source location Response from Rotherham District General Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include learning from the incident in the Quality Newsletter, focusing on acting upon time-critical blood results.
Verbatim wording from the response “The Deputy Chief Nurse in conjunction with colleagues from the learning from deaths programme, clinical effectiveness team and the quality governance team will include the learning from this incident in the Quality Newsletter focusing on the importance of acting upon time critical blood results.” Source location Response from Rotherham District General Hospitals
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1 Feb 2023 Hugo Carlos · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Failure of the practice follow-up system to ensure investigations are completed at the correct time 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
Hugo Carlos · 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
Hugo Carlos died in November 2021 after developing obstructive jaundice caused by a liver lesion and undergoing procedures including biliary drain insertion and hepatic artery embolization. The principal concern was that the EMIS system did not reliably alert general practitioners when follow-up investigations were due, placing responsibility on patients and creating a continuing risk that patients could be lost to necessary follow-up.
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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 the practice follow-up system to ensure investigations are completed at the correct time
Wider context from the report “A partner in the Deceased’s general practice gave evidence to the Inquest that the practice uses the EMIS system, and that, unlike SystemOne, the system does not have a scheduled task feature which would allow the GP to create an alert on a patient’s record to flag up when a task is due at a future date – eg an alert to book a follow up scan in one year.
I have been informed that EMIS does allow a future entry into a patient’s record (a diary date), but this must be for a specific clinical code and the only way to see that there is a due diary date entry is to access the patient’s record and view the summary page or diary section. Unless the GP has reason to inspect the patient’s clinical record and examine the summary or diary pages there is no way of being alerted that a new task needs to be completed for that patient . Further, it is not possible to add a pop-up linked diary date entry for a specific task (such as a scan) outside the EMIS determined list .
This creates a situation where the responsibility for ensuring that follow up investigations are undertaken at the correct time is placed onto the patient , and the patient will have to contact the GP to request follow-up.
In this case the Deceased was diligent in contacting his GP surgery to request repeat scans, but I consider that unless some action is taken there is a continuing risk of patients not contacting the GP to make a request for follow-up and therefore becoming lost to necessary follow-up .
” Source location Hugo Carlos · Prevention of Future Deaths report
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24 May 2022 Michael Nestor WYSOCKYJY · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Lack of escalation arrangements for outstanding x-ray requests View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Michael Nestor WYSOCKYJY · 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
Michael Nestor WYSOCKYJY became unwell on 20 September 2021 and was taken to Queen Elizabeth Hospital, where delays occurred before a chest x-ray was performed. A large right-sided pneumothorax was identified shortly before he suffered cardiac arrest and was pronounced dead. Concerns related to delays in ambulance offloading and the lack of clear escalation arrangements to ensure requested x-rays were completed in a busy emergency department.
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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 escalation arrangements for outstanding x-ray requests
Wider context from the report “2. The need for an x-ray remains with the nurse, nurse in charge and/or doctor. If an x-ray is not carried out, the request remains with the nurse, nurse in charge and/or doctor and it was not clear from the evidence there is anything in place to ensure this is escalated and the x-ray takes place . This is something that can be missed in a busy department .
” Source location Michael Nestor WYSOCKYJY · 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 Upgrade the Emergency Department two-hourly-round checklist to prompt escalation of outstanding investigations, including imaging and blood tests.
Verbatim wording from the response “Response:
The Emergency Department does operate a system whereby two hourly rounds are conducted for patients in the department. This is carried out by the Band 7 nurse in charge and involves a checklist of clinical and other criteria to ensure that if clinically indicated, appropriate escalation takes place. The intention is that amongst all the other parameters if an investigation such as imaging or blood tests is awaited, this should also be escalated if there is a need to do so. However, it is correct to say that at the time of the inquest the check list contained no specific reference to investigations. The checklist has therefore been upgraded to include this (new version attached with the amendment highlighted).” Source location Response from NHS Queen Elizabeth Hospital Kings's Lynn
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9 May 2021 Eva Hayden · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Failure to follow up missed appointments for investigation of neutropenia View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Mersey and West Lancashire Teaching 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. 6
Mersey and West Lancashire Teaching Hospitals NHS Trust
Schedule and clinically annotate ward-attender appointments electronically to track attendance and record outcomes.
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Mersey and West Lancashire Teaching Hospitals NHS Trust
Require consultant clinical review and documented follow-up for every child not brought to a scheduled outpatient or ward-attender appointment.
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Mersey and West Lancashire Teaching Hospitals NHS Trust
Audit the outpatient non-attendance pathway and review cases where children were not clinically reviewed.
View source
Mersey and West Lancashire Teaching Hospitals NHS Trust
Revise the Did Not Attend policy into a corporate Was Not Brought policy incorporating required safeguards and best-practice principles.
View source
Mersey and West Lancashire Teaching Hospitals NHS Trust
Conduct monthly audits of adherence to the updated Was Not Brought policy and processes, escalating breaches through governance and incident-management arrangements.
View source
Mersey and West Lancashire Teaching Hospitals NHS Trust
Amend paediatric staff induction to cover communication with families, communication with other organisations, and responses when children are not brought to appointments.
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AI-generated summary
Eva Hayden · 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
Eva Hayden, aged four, developed neutropenia following an illness and later became seriously unwell with fever-like symptoms. She collapsed on 10 January 2020 and died in the emergency department on 11 January 2020; the inquest found sepsis and bone marrow hypoplasia. Concerns included missed follow-up of her neutropenia, inadequate communication between hospitals, and insufficient communication with her parents about infection risks.
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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 follow up missed appointments for investigation of neutropenia
Wider context from the report “b) When Eva missed the appointment at Ormskirk Hospital on the 25th November 2019 for her blood tests – there was no follow up by the hospital as there was an “assumption” that a follow-up orthopaedic appointment for cellulitis would investigate her neutropenia . The assumption was wrong and there was no clinical communication between the Trusts, which would have clarified that investigation of neutropenia had ceased without resolution. The onus for investigations cannot be on a four year old or her parents who were unaware of the potentially fatal implications.
” Source location Eva Hayden · 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 Schedule and clinically annotate ward-attender appointments electronically to track attendance and record outcomes.
Verbatim wording from the response “1. At the time of this event there were paper-based systems in use, this has now changed and ward attender appointments are now scheduled on Medway (PAS) and clinically annotated at the time of the attendance. This ensures that patients are tracked and diarised electronically with outcomes recorded on the patient system.” Source location 2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require consultant clinical review and documented follow-up for every child not brought to a scheduled outpatient or ward-attender appointment.
Verbatim wording from the response “3. The Trust immediately implemented safeguards to prevent a similar incident occurring when a child is not brought to a scheduled outpatient or ward attender appointment. All non-attendances are sent to the Consultant in charge of the care to clinically review and agree on what course of action needs to be taken. Examples of further actions could include, another appointment being offered or a discussion with another Trust if there are shared care arrangements. In all cases there will be documented evidence of the follow-up action that has taken place, e.g. letter to GP and/or parents.” Source location 2021-0147-Response-from-Southport-and-Ormskirk-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 Audit the outpatient non-attendance pathway and review cases where children were not clinically reviewed.
Verbatim wording from the response “4. We have completed a full audit exercise to look at the pathway and scenario that Eva was under as she was those patients that attend through a standard outpatient appointment. Whilst this identified that in the majority of cases, the existing DNA Policy and processes were followed; there were 5 occasions where a patient didn’t attend an outpatient appointment and wasn’t clinically reviewed. Each incidence has been reviewed and there were no incidents of harm identified as a result.” Source location 2021-0147-Response-from-Southport-and-Ormskirk-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 Revise the Did Not Attend policy into a corporate Was Not Brought policy incorporating required safeguards and best-practice principles.
Verbatim wording from the response “5. We have reviewed our ‘Did Not Attend (DNA)’ Policy to reflect the requirements of the Regulation 28 report and ensure that any necessary safeguards from the work described above are contained within the policy. The Policy has also been re-vamped to ensure it reflects best practice and principles that a child ‘Was Not Brought’ as opposed to DNA. The updated policy is due to be presented at the clinical business unit (CBU) governance meeting on 08/07/2021 and will be subject to the governance arrangements of the Trust. The Was Not Brought Policy is a corporate Policy and will apply to all children anywhere within the trust.” Source location 2021-0147-Response-from-Southport-and-Ormskirk-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 Conduct monthly audits of adherence to the updated Was Not Brought policy and processes, escalating breaches through governance and incident-management arrangements.
Verbatim wording from the response “6. We are confident that the implementation of the actions described in points 3 and 5 above will ensure that there is a clear response each time a child is not brought to an appointment and we have introduced a routine audit to be undertaken every month to measure that our updated policy and processes are being adhered to. This will be monitored through speciality and CBU governance arrangements with any breaches against the policy being escalated through the Trust incident management processes.” Source location 2021-0147-Response-from-Southport-and-Ormskirk-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 Amend paediatric staff induction to cover communication with families, communication with other organisations, and responses when children are not brought to appointments.
Verbatim wording from the response “10. The circumstances and details of this case have been widely shared. In addition, we are amending the local induction for staff in paediatrics to ensure that staff are provided with important information about the requirements of:” Source location 2021-0147-Response-from-Southport-and-Ormskirk-Hospital-Redacted
Open published response
16 Dec 2019 Shirley Anne Nightingale · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of a clear system to follow up required OGD before the next-day AMU ward round 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
Shirley Anne Nightingale · 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
Shirley Anne Nightingale died at Tameside General Hospital on 20 May 2019 after a catastrophic gastrointestinal bleed. The report identified concerns about the lack of clear systems for prioritising urgent endoscopies, following up requests, and recording or authorising departures from recommended timescales.
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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 a clear system to follow up required OGD before the next-day AMU ward round
Wider context from the report “2. The inquest heard that it had been identified in Accident and Emergency that the OGD was required. The notes were marked accordingly but there was no clear system to ensure that this was followed up prior to the ward round on AMU the next day ;
” Source location Shirley Anne Nightingale · Prevention of Future Deaths report
Open source report
28 Nov 2017 Mr Harold Chapman · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Lack of checks to ensure review of requested investigations and appropriate action in line with guidelines 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
Mr Harold Chapman · 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 Harold Chapman, who had hypertrophic cardiomyopathy, died on 14 June 2016 after developing a significant cardiac arrhythmia. The inquest found that non-sustained ventricular tachycardia identified in 2015 was not reviewed promptly, delaying consideration of an implantable cardioverter defibrillator. A further concern was that patient emails sent to consultants were often not viewed or acted upon, with no response provided.
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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 checks to ensure review of requested investigations and appropriate action in line with guidelines
Wider context from the report “(1) the consultant responsible for Mr Chapman’s care in August and November 2015 was based, at the time, at Barts NHS Trust and is now employed by the Brompton. The consultant was responsible for reviewing the investigations that he (and other members of his team in their absence) had requested.
(2) There appeared to be no check mechanisms in place to ensure that this was done and appropriate action taken in line with the Guidelines..
” Source location Mr Harold Chapman · 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 compliance with ESC 2014 guidelines for diagnosing and managing hypertrophic cardiomyopathy.
Verbatim wording from the response “The RBHT Sudden Cardiac Death (SCD) Service is reviewing compliance with the European Society of Cardiology (ESC) 2014 guidelines on diagnosis and management of hypertrophic cardiomyopathy. The RBHT Cardiomyopathy service (which includes SCD patients) is consultant delivered with a specialist consultant present in every clinic. Clinic letters have a standardised format including risk stratification for SCD risk (calculated using the SCD calculator) which includes regular Holter rhythm monitoring as per the ESC 2014 guidelines. All Holter tapes are reported by trained cardiac physiology technicians and findings of concern are communicated directly to the referring consultant by phone or email (if requested by a fellow). Holter monitor reports are uploaded into the electronic patient record (EPR) along with all other investigation results.” Source location 2017-0377-Response-by-Royal-Brompton-Harefield-NHS-Trust
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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 Report Holter recordings through trained physiology technicians, communicate concerning findings to referring consultants, and upload reports to electronic patient records.
Verbatim wording from the response “The RBHT Sudden Cardiac Death (SCD) Service is reviewing compliance with the European Society of Cardiology (ESC) 2014 guidelines on diagnosis and management of hypertrophic cardiomyopathy. The RBHT Cardiomyopathy service (which includes SCD patients) is consultant delivered with a specialist consultant present in every clinic. Clinic letters have a standardised format including risk stratification for SCD risk (calculated using the SCD calculator) which includes regular Holter rhythm monitoring as per the ESC 2014 guidelines. All Holter tapes are reported by trained cardiac physiology technicians and findings of concern are communicated directly to the referring consultant by phone or email (if requested by a fellow). Holter monitor reports are uploaded into the electronic patient record (EPR) along with all other investigation results.” Source location 2017-0377-Response-by-Royal-Brompton-Harefield-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 Existing GMC and NHS England guidance provides an adequate framework for safe communication with patients and handling test results.
Verbatim wording from the response “I hope this information is helpful and provides assurance that there is guidance available to clinicians in this area. Where there are concerns about the conduct of an individual clinician, these should be brought to the attention of the GMC as regulator.” Source location 2017-0377-Response-by-Department-of-Health
Open published response
22 May 2015 Olive Darbyshire · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 1
Failure of the clinical team to follow up missing CTPA procedures View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Olive Darbyshire · 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
Olive Darbyshire fell while trying to get from her bed to the toilet, suffered a hip fracture, and was admitted to hospital. An urgent CT pulmonary angiogram requested after suspected pulmonary embolism was not carried out after she was incorrectly categorised as an outpatient, and she later developed a major intestinal bleed and died on 28 December 2014. Concerns included the failure to complete or follow up the urgent scan and the effects of incorrect categorisation and reduced Christmas-period staffing.
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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 the clinical team to follow up missing CTPA procedures
Wider context from the report “2. I am concerned that according to the Radiology department there is no record of the clinical team responsible for Mrs Darbyshire's care making efforts to “chase up” the missing CTPA procedure .
” Source location Olive Darbyshire · 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 Create a standard operating procedure for recording and tracing diagnostic-request status changes, messages, requested actions and authorisation.
Verbatim wording from the response “There have been several meetings of key team leaders and staff to look at how the Trust can put in place measures to reduce the weaknesses regarding the status of diagnostic requests, identification of the individual making the request, messaging and follow up.” Source location Olive-Darbyshire-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ratify the procedure within the directorate, submit it to the electronic Trust document library, and provide paper copies in key radiology areas.
Verbatim wording from the response “This will be ratified within the directorate and submitted to the Trust document library, where it can be accessed electronically by all staff, at any time.” Source location Olive-Darbyshire-Response
Open published response
17 Apr 2015 Robert Watt · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure to identify scheduled investigations before hospital discharge 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.
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AI-generated summary
Robert Watt · 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
Robert Watt had suspected bladder cancer symptoms, including haematuria, weight loss and rectal bleeding, but investigations and specialist review did not identify the cancer until it was advanced and incurable. The report identified concerns about communication of a cancelled haematuria clinic appointment, incomplete medical records, reliance on junior doctors for specialist advice, and the lack of urological review when malignancy was suspected.
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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 scheduled investigations before hospital discharge
Wider context from the report “vi. The evidence has shown (although it does not relate to the death) that Mr. Watt was discharged from the hospital even though he was scheduled to have an OGD at the hospital on the date of discharge , which it appears that the physicians were unaware of .
” Source location Robert Watt · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.