Recurring concern

Failure to seek medical attention when a person's condition warrants it

First to latest report 5 Sep 2013 — 16 Jun 2026

Reports that mention this concern
56
Times this concern has been raised
61
Stated actions linked to this concern
81

What this concern includes

Includes failures to recognise the need for and promptly seek medical, paramedic or other appropriate clinical assistance when a person's injury, pain, fall, deterioration or other condition warrants it, including failures in care homes and emergency-response settings.

What is not included
  • Excludes delays or failures occurring after medical assistance has already been requested, including ambulance attendance or hospital handover delays.
  • Excludes failures limited to the quality of assessment or treatment after medical assistance has been obtained.
  • Excludes failures to seek advice about routine care arrangements where no immediate or clinically warranted need for medical attention is identified.
  • Excludes generic staffing, training, communication or documentation deficiencies unless they directly result in failure to seek warranted medical attention.

Reports and published responses 56 reports

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

  1. North West Kent

    AI-generated summary

    Jonathan Richard McCARTHY · 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

    Jonathan Richard McCarthy was admitted to hospital with confusion, aspiration pneumonia, sepsis, acute kidney injury and swallowing difficulties, and later deteriorated with another aspiration pneumonia and hyperglycaemia. The stated concerns were failures to correctly monitor blood sugar and ketones, administer the correct insulin dose, and provide adequate nursing care and escalation to the medical team.

    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 to the medical team

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The Trust failed to correctly monitor the blood sugar and ketone testing of Jonathan Richard McCarthy (2) The Trust failed to administer the correct does of insulin (3) There was inadequate nursing care and a failure to escalate to the medical team when it was clear this should be carried out. ”

    Source location

    Jonathan Richard McCARTHY · 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 the approved blood-glucose monitoring guideline, including traffic-light interpretation, hypoglycaemia management and escalation procedures.

    Verbatim wording from the response

    “It was identified during the Serious Incident investigation that the staff concerned were unsure of the appropriate procedures relating to the monitoring of blood sugar and ketone testing therefore a Trust Guideline for capillary blood glucose monitoring for inpatients and day cases with Diabetes Mellitus over the age of 16 years has been written and approved by the Medical Specialities Directorate. This guideline is in keeping with the standard set by the National Inpatient Diabetes Audit. The guideline has been out for wide consultation with comments from clinicians across the trust being received. Contained within the Guideline is a coloured “traffic light” risk tool to assist staff on the wards to interpret the results of blood sugar and ketone testing, with recommended actions to undertake and escalation as appropriate.”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 1 · response
    Published 14 August 2019

    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 monthly induction training for clinical support workers, registered nurses and junior doctors on diabetic monitoring, equipment, escalation and referrals.

    Verbatim wording from the response

    “Ongoing monthly training has been in place for new Clinical Support Workers and Registered Nurses and this is undertaken during their first weeks on induction to the trust where diabetic management is highlighted in bite-sized sessions. This is delivered by the Diabetes Specialist Nurses on both sites. This demonstrates the use of equipment (by the Point of Care Team), the new algorithm for the recognition and management of hyper- and hypo-glycaemia and how to request in-patient referrals to the Diabetes Team and escalate for medical attention. The Blood Glucose Guideline also forms part of the Junior doctors induction programme which is also undertaken by the Diabetes Team.”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 1 · response
    Published 14 August 2019

    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

    Deliver targeted staff training and share case learning on testing, abnormal-result response and escalation to medical or diabetes teams.

    Verbatim wording from the response

    “As outlined in response to question (1), this aspect of Mr McCarthy’s care has been addressed directly with the staff concerned on those on the ward with specific training and the learning from Mr McCarthy’s case has been shared. The introduction of the algorithm, the raised awareness of the importance of testing and acting/escalating abnormal results have been outlined and incorporated into the new guidance. This includes the element of how and when to escalate to medical teams or diabetic nurse specialists for assistance and review.”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 2 · response
    Published 14 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and introduce connected blood-glucose and ketone meters with real-time dashboard escalation, replacing existing meters and training staff.

    Verbatim wording from the response

    “The Trust has also been out to tender for a blood glucose and ketone testing meter that has the capability of linking into the existing clinical observation monitoring tool (Nervecentre) which would record and escalate results accordingly. In addition blood ketone testing machines have been purchased and assigned to key locations in the trust with the aim to ultimately have them on each ward. The Emergency Departments on both sites have these in place and appropriate training has been rolled out to the nursing staff. In addition the Diabetic Nurse Specialists also carry ketone testing machines to support access and training to the ward staff as and when required.”

    Source location

    2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
    Page 2 · response
    Published 14 August 2019

    Open published response

  2. Inner South London

    AI-generated summary

    Mr Royston Kemp · 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 Royston Kemp, an 85-year-old care home resident with dementia and a history of fractures and falls, suffered an unwitnessed traumatic fracture of his left femur in February 2016. He was not referred to hospital until two days after signs of injury and died on 20 March 2016 from pneumonia, aspiration and advanced dementia, with the fracture-related immobility identified as a key contributor. Concerns included failure by a nurse to act on leg swelling and temperature differences, establish the care assistant’s concerns, measure vital signs, or escalate for medical assessment and referral.

    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 to medical care or refer

    Wider context from the report

    “A nurse working at Marlborough Court Care Home, who has already been referred to the NMC assessed this frail elderly resident whose leg caused concern to care assistants. In doing so her evidence concerned the coroner was: 1) She found one leg more swollen than the other and of a different temperature but took no action 2) She failed to establish the care assistant’s concern or whether she had met the concern before or after her assessment 3) She failed to measure Vital Signs 4) She failed to escalate to medical care or refer, in the process failed to enable a diagnosis of fractured femur to be made. ”

    Source location

    Mr Royston Kemp · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Brighton and Hove

    AI-generated summary

    Ioannis AVGOUSTI · 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

    Ioannis Avgousti died after an episode involving documented allergy to Co-Amoxiclav, during which the medication was prescribed and administered. The report identified concerns about failure to follow allergy guidance, inadequate communication, failure to act on elevated NEWS observations or escalate care, and staffing pressures during the relevant shift.

    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 act on NEWS observations and escalate deteriorating patients

    Wider context from the report

    “(2) On the 6th October 2018 although the hospital had noted that he was allergic to Co-Amoxiclav and although the paper medication notes noted that fact he was written up for that medication and it was administered to him. I saw evidence of a poorly documented, from the point of view of time, NEWS observation. Although at the top of the chart there were the numbers 2 0 (20) I found on the balance of probabilities that set of observations had more likely been taken at about 20:10 or 20:15 hours. The observations were added up to 9. In fact the total was 13. NEWS is a tool to ensure that the deteriorating patient is recognised and given help and escalated, if appropriate, to Intensive Care. This set of observations was not acted on in accordance with the directions and no escalation was made. There should have been a MET call then i.e., at around 20:15 hours to a specialist registrar (there was one on duty) If this call had been made and if the appropriate doctor had been called to see Mr. Avgousti it is possible that although the sepsis protocol would I believe have been implemented, it would have been realised that he had an allergy to Co-Amoxiclav and he would have been given an appropriate alternative. Whilst I cannot say categorically that this would have been the case I believe it is highly likely. NEWS is an important tool and should not be ignored as it was on Vallance Ward on the night of the 6th October 2018. ”

    Source location

    Ioannis AVGOUSTI · 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

    Expand the Critical Care Outreach service to support immediate escalation from electronic NEWS scores.

    Verbatim wording from the response

    “Critical Care Outreach service, of which we are expanding, so escalation will be immediate rather than reliant on staff on the ward calculating the scores and putting out a MET call.”

    Source location

    2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
    Page 3 · response
    Published 14 June 2019

    Open published response

  4. Manchester North

    AI-generated summary

    Dr Donald Clegg · 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

    Dr Donald Clegg, who had complex physical and mental health needs, was transferred to a short-term residential placement that was unable to manage his care needs. Concerns included inadequate assessment and communication during the transfer, unsafe medication management, insufficient monitoring, delayed recognition of deterioration and inadequate record keeping. He developed breathing difficulties and seizure-like activity on 26 February 2018, was admitted to hospital and died later that day; the stated cause of death was acute left ventricular heart failure due to severe ischaemic heart disease and left ventricular hypertrophy.

    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

    Delays in seeking medical attention when service users deteriorate

    Wider context from the report

    “4. Staff were unable to recognise the deteriorating adult and did not seek medical attention in a timely manner when signs of change became apparent. This potentially puts service users at risk of harm/death. ”

    Source location

    Dr Donald Clegg · 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

    Review and develop training to help staff recognise deterioration, question medical professionals, and identify triggers for seeking further advice.

    Verbatim wording from the response

    “4. Staff were unable to recognise the signs of deterioration and did not seek medical attention in a timely manner This finding is one which we have reflected on at some length. As you will be aware, Elmhurst does not hold a Nursing registration and the staff we employ are social care staff and not medically qualified. Therefore the monitoring that we undertake when someone is unwell needs to be appropriate to the specifics of our registration. Having reflected and reviewed our approach I believe that this service would benefit from additional training and we also need to empower staff to ask more and better questions of medical professionals in order to understand what to expect, and what triggers to look for in an individual’s specific case in order to know when to seek further advice or involve medical professionals.”

    Source location

    2018-0269-Response-by-Persona
    Page 3 · response
    Published 25 October 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

    Monitoring of unwell service users is limited to what is appropriate for Elmhurst’s social-care registration and staff’s non-medical qualifications.

    Verbatim wording from the response

    “4. Staff were unable to recognise the signs of deterioration and did not seek medical attention in a timely manner This finding is one which we have reflected on at some length. As you will be aware, Elmhurst does not hold a Nursing registration and the staff we employ are social care staff and not medically qualified. Therefore the monitoring that we undertake when someone is unwell needs to be appropriate to the specifics of our registration. Having reflected and reviewed our approach I believe that this service would benefit from additional training and we also need to empower staff to ask more and better questions of medical professionals in order to understand what to expect, and what triggers to look for in an individual’s specific case in order to know when to seek further advice or involve medical professionals.”

    Source location

    2018-0269-Response-by-Persona
    Page 3 · response
    Published 25 October 2018

    Open published response

  5. Surrey

    AI-generated summary

    Rita 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

    Rita Taylor was admitted to hospital with severe hyponatraemia in the context of diabetes insipidus and a pituitary adenoma, and died on 15 August 2017 after developing central pontine myelinolysis. The principal concerns were failures to appropriately monitor and manage her sodium levels and diabetes insipidus, including omission of desmopressin, inadequate fluid-balance assessment, insufficient documentation, and lack of a coherent management plan.

    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 obtain appropriate specialist assistance for hyponatraemia management

    Wider context from the report

    “1. The failure to appropriately manage Mrs Taylor’s hyponatraemia by the on call consultant physician on the 31st July 2017 on the grounds that it was not his sphere of expertise. No contact was considered or made to someone who may have been able to assist leaving Mrs Taylor to languish overnight with no management plan in place and a lack of any meaningful documentation in her hospital notes. ”

    Source location

    Rita Taylor · Prevention of Future Deaths report
    Page 4 · 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

    Classify desmopressin as a high-risk drug requiring specialist advice before discontinuation and a plan for reintroduction.

    Verbatim wording from the response

    “Response - Recommendation 5 of the Action Plan sets out that; ‘Desmopressin should be notified as a high risk drug that should not be discontinued without specialist advice.’ The specialist providing the advice to discontinue the drug will ensure that there is a plan in place to reintroduce the drug at an appropriate time. This action has been implemented by the Medicines Management Committee with input from the pharmacy department.”

    Source location

    2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
    Page 4 · response
    Published 23 September 2018

    Open published response

  6. Manchester North

    AI-generated summary

    Miss Lea Louise Hunsley · 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

    Lea Hunsley, who had profound cerebral palsy and complex healthcare needs, became increasingly unwell while in respite care on 9 July 2016 and died after cardio-respiratory arrest at Wythenshawe Hospital Emergency Department shortly after midnight on 10 July 2016. The report identified missed opportunities to assess, escalate and intervene, and raised concerns about the facility’s lack of protocols, staff’s ability to recognise deterioration, inadequate observations and monitoring, failure to use care records appropriately, and insufficient action following a CQC inspection.

    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 deteriorating patients for medical review

    Wider context from the report

    “2. Registered Nurse/s and Carers at EAM: i) lack the ability to identify, recognise and act upon the deteriorating patient; ii) in this case, did not escalate for medical review (no policy/protocol exists for the same); iii) demonstrated a poor standard of basic (physiological) observation and monitoring & iv) failed to read and use the care records appropriately (in particular, the RN did not read important/critical entries on the 9th at all). ”

    Source location

    Miss Lea Louise Hunsley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop deteriorating-patient protocols tailored to each young person’s care needs.

    Verbatim wording from the response

    “future we would obtain a post-operative care plan or information from the Consultant, following a multi-disciplinary meeting, ahead of any proposed stay in order that we may assess the support needs. If the risks associated exceeded our capabilities then we would not proceed with an admission, until the risks associated had sufficiently reduced. Any post-surgical admissions would include a post-operative care plan, prior to admission, to ensure that all staff involved in the young person’s care were adequately up to date in their support needs. We are currently developing deteriorating patient protocols specific to each young person’s care needs. These are to be in place in the next three months.”

    Source location

    2018-0101-Response-by-EAM-Care-Group
    Page 2 · response
    Published 17 June 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

    Establish escalation of family, carer or professional concerns to primary care, out-of-hours services or paramedics regardless of nursing observations.

    Verbatim wording from the response

    “• If any family member, carer or professional had concerns we would now escalate to GP/Out of Hours service or Paramedic, even if the Registered Nurse’s observations show no concerns.”

    Source location

    2018-0101-Response-by-EAM-Care-Group
    Page 2 · response
    Published 17 June 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 an updated When to Seek Medical Advice policy, requiring staff acknowledgement and signatures and addressing family concerns.

    Verbatim wording from the response

    “• There is now an updated When to Seek Medical Advice policy that staff have read and signed which advises when to seek medical help and to listen to family concerns.”

    Source location

    2018-0101-Response-by-EAM-Care-Group
    Page 3 · response
    Published 17 June 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

    Update the hospital admission and discharge policy to include When to Seek Medical Advice guidance.

    Verbatim wording from the response

    “• Hospital admission/discharge policy updated with ‘When to Seek Medical Advice’ now included in the policy.”

    Source location

    2018-0101-Response-by-EAM-Care-Group
    Page 3 · response
    Published 17 June 2018

    Open published response

  7. Nottinghamshire

    AI-generated summary

    Joan Osborne · 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

    Joan Osborne, who had diabetes and advanced dementia, died on 25 August 2017 after repeated difficulties obtaining her blood glucose levels and administering her insulin. The concerns included failures by nursing home staff to seek medical assistance or escalate her missed insulin, inadequate records, failure to recognise her deteriorating condition, and inaccurate blood glucose measurement and treatment on 22 August 2017.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to seek medical assistance when insulin is refused over an extended period

    Wider context from the report

    “(3) The nursing home staff did not seek medical assistance for Mrs Osborne when she refused to have her insulin prescription over an extended period, on two separate occasions, leading to her hospitalisation on 12.08.2017 and 22.08.2017. ”

    Source location

    Joan Osborne · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to seek urgent GP attention during attendance at the home

    Wider context from the report

    “(6) The nursing home staff did not recognise the need, nor seek help, for Mrs Osborne’s deteriorating condition on 22.08.2017 and did not seek the urgent attention of her GP upon his usual attendance at the home on that date. ”

    Source location

    Joan Osborne · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to recognise and seek help for a deteriorating condition

    Wider context from the report

    “(6) The nursing home staff did not recognise the need, nor seek help, for Mrs Osborne’s deteriorating condition on 22.08.2017 and did not seek the urgent attention of her GP upon his usual attendance at the home on that date. ”

    Source location

    Joan Osborne · 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

    Prioritise diabetes care planning, including instructions for seeking medical assistance when insulin or medication is refused.

    Verbatim wording from the response

    “Care planning with regards to diabetes management has been prioritised, as part of the lessons learned, and where required care plans include details with regards to when and how to seek medical assistance if insulin/medication is refused by a resident.”

    Source location

    2018-0091-Response-by-Adbolton-Hall-Ltd
    Page 3 · response
    Published 16 June 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

    Meet with the visiting GP to provide oversight of improvements and establish direct notification of future concerns.

    Verbatim wording from the response

    “Additionally, on the 20 March 2018 the Home Manager met with the GP who visits Adbolton Hall to outline those many improvements that have been made as detailed above. This has provided valuable oversight and input from the GP and the Home Manager has also asked that he make her directly aware of any issues or concerns that he may have in the future.”

    Source location

    2018-0091-Response-by-Adbolton-Hall-Ltd
    Page 4 · response
    Published 16 June 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

    Deliver Nutrition and Diabetes Management Training to nursing home staff.

    Verbatim wording from the response

    “(3) The nursing home staff have received Nutrition and Diabetes Management Training. There were three separate sessions of this training, delivered at ‘Adbolton Hall’, on the 30/10/2017, 07/11/2017 and 30/11/2017. This training was delivered by ████████ a Community Dietician from the Clinical Commissioning Group. This training included Management of Type 2 Diabetes, Treatments of Hypoglycaemia and Dietary Needs.”

    Source location

    2018-0091-Response-by-Adbolton-Hall-Ltd
    Page 3 · response
    Published 16 June 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

    Diabetes care is considered adequately assessed and provided because relevant authorities were satisfied the home’s complex-needs admissions were safe.

    Verbatim wording from the response

    “their pre-admission assessments were sent to ████████, Management Officer for the Quality and Market Management Team within Nottinghamshire County Council, and ████████, Care Home Quality Lead Nottingham North and East, Nottingham West and Rushcliffe Clinical Commissioning Group, to ensure that they were confident that the home could meet each individual’s needs. On 26 March 2018, ████████ advised the home that they were not required to continue to send these to them, as they were satisfied that all the home’s admissions, including those with individuals with complex needs, were safe. We are confident therefore that diabetes care is adequately assessed and provided for.”

    Source location

    2018-0091-Response-by-Adbolton-Hall-Ltd
    Page 4 · response
    Published 16 June 2018

    Open published response

  8. Staffordshire South

    AI-generated summary

    John Keith Edwards · 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 Keith Edwards, aged 64, was admitted to a care home for respite and subsequently suffered falls, seizures, reduced mobility, pressure sores and a rapid decline before dying in a nursing home on 19 December 2016. Concerns included inadequate care-home policies and care, failures to seek medical assistance and recognise deterioration, poor record-keeping, and inappropriate placement for his complex needs.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to seek medical assistance following seizures

    Wider context from the report

    “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate (2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care (3) Care Home staff applied a seizure policy which was not specific to the resident. (4) Care Home staff failed to seek medical assistance following seizures. (5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home. (6) Care records were retrospectively filled in. (7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done. (8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP. (9) Non patient specific dressings were used on pressure sores. (10) A non-patient specific mattress was used on his bed. (11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition. ”

    Source location

    John Keith Edwards · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to seek and communicate appropriate medical follow-up for deteriorating residents

    Wider context from the report

    “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate (2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care (3) Care Home staff applied a seizure policy which was not specific to the resident. (4) Care Home staff failed to seek medical assistance following seizures. (5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home. (6) Care records were retrospectively filled in. (7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done. (8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP. (9) Non patient specific dressings were used on pressure sores. (10) A non-patient specific mattress was used on his bed. (11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition. ”

    Source location

    John Keith Edwards · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Medical advice was sought appropriately, and no urgent referral was recommended or documented by the out-of-hours doctor.

    Verbatim wording from the response

    “7. Medical advice for Mr Edwards was sought at the appropriate time. The Doctor was provided with full information and all questions raised by him were answered. There is no recollection as to the out of hours Doctor suggesting any urgent referral and no documentation (other than a prescription – which was obtained straight away) was left by the Doctor.”

    Source location

    2018-0015-Response-Southwinds-Limited
    Page 2 · response
    Published 7 March 2018

    Open published response

  9. Avon

    AI-generated summary

    Irene Winifred BAKER · 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

    Irene Winifred BAKER died following an operation for a fractured hip, which evidence suggested occurred at Rosewood Lodge Nursing Home, although the nursing home had no record of it. Concerns included failures to revise mobility care plans, undertake monthly mobility reviews, and contact a GP or call an ambulance when she was documented as unable to bear weight.

    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 documented inability to weight-bear to the GP or ambulance service

    Wider context from the report

    “3. A failure to contact the GP or call an ambulance in response to a documented inability to weight-bear 12th - 23rd April 2017 ”

    Source location

    Irene Winifred BAKER · 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

    Raise requests for medical-professional support immediately when residents’ needs require it.

    Verbatim wording from the response

    “• Care plans are reviewed on a monthly basis or before if there are any changes, risk assessments are updated accordingly and support from medical professionals is raised immediately to ensure we are able to meet their needs at all times.”

    Source location

    2017-0362-Response-by-Rosewood-Lodge
    Page 1 · response
    Published 11 February 2018

    Open published response

  10. Inner North London

    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.

    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 obtain medical review 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
    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

    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
    Page 1 · response
    Published 4 February 2018

    Open published response

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