28 Jun 2023 Carol Ann Hatch · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to report concerns about clinicians’ competence to regulatory bodies View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
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Carol Ann Hatch · 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
Carol Ann Hatch underwent repeat hiatus hernia surgery at a private hospital on 31 August 2022 and became unwell overnight. She was transferred to an NHS hospital, treated for septic shock and organ failure for six weeks, and died on 18 October 2022. The report identifies concerns about overnight monitoring, escalation, staffing competence, record-keeping, and delays in investigations and treatment; evidence at the Inquest indicated that the failings contributed to her death.
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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 report concerns about clinicians’ competence to regulatory bodies
Wider context from the report “12. Overall, the cluster of failings on 31 August/1 September brought into question the competence of the staff looking after Mrs Hatch on duty at the Spire Hospital that night. The Inquest was informed that such concerns had not been reported to the regulatory bodies of those involved , The RMO continues to practice at the Spire Hospital.
” Source location Carol Ann Hatch · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Referral of the RMO to the GMC was considered unnecessary because the RCA findings and known practice did not meet the referral threshold.
Verbatim wording from the response “Evidence was heard at the inquest that consideration was given to referring the RMO to the GMC following this incident. The RMO’s skill set, and competency were discussed at a Scrutiny Panel on 17th February 2023 attended by hospital and senior clinical and medical management at Spire. It was concluded that the findings of the RCA and the known practice of the RMO did not meet the threshold for referral to the GMC. It was agreed that the hospital team would share the RCA with the RMO’s agency, which was completed on 16th March 2023. It was agreed that the RMO’s agency were best placed to assist us in understanding whether this was an isolated episode or not, whether there were any wider performance concerns that needed to be addressed or matters requiring escalation to the GMC.” Source location Response from Spire Healthcare Limited
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The RMO’s agency was considered best placed to assess whether the incident was isolated or required wider performance action or GMC escalation.
Verbatim wording from the response “Evidence was heard at the inquest that consideration was given to referring the RMO to the GMC following this incident. The RMO’s skill set, and competency were discussed at a Scrutiny Panel on 17th February 2023 attended by hospital and senior clinical and medical management at Spire. It was concluded that the findings of the RCA and the known practice of the RMO did not meet the threshold for referral to the GMC. It was agreed that the hospital team would share the RCA with the RMO’s agency, which was completed on 16th March 2023. It was agreed that the RMO’s agency were best placed to assist us in understanding whether this was an isolated episode or not, whether there were any wider performance concerns that needed to be addressed or matters requiring escalation to the GMC.” Source location Response from Spire Healthcare Limited
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15 Feb 2023 Raniya Rizwan Khan · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Failure to refer concerns about an agency midwife to the Nursing and Midwifery Council View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Royal Berkshire Hospital
Strengthen the policy requiring concerns about temporary agency staff to be reported when they no longer work at the Trust.
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Raniya Rizwan Khan · 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
Raniya Rizwan Khan was born on 9 May 2020 and died at Great Ormond Street Hospital on 28 May 2020 after her condition deteriorated; the recorded cause of death was multi-organ failure and severe arterial pulmonary hypertension of unknown cause. Concerns included failures in labour monitoring and escalation by an agency midwife, and the reported non-completion of trust undertakings concerning placenta retention, related procedures and staff training.
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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 refer concerns about an agency midwife to the Nursing and Midwifery Council
Wider context from the report “I was also advised that there has been no approach made to NHS Professionals about concerns with the midwife in question. Similarly, no approach to the NMC has been made .
” Source location Raniya Rizwan Khan · Prevention of Future Deaths report
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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 Strengthen the policy requiring concerns about temporary agency staff to be reported when they no longer work at the Trust.
Verbatim wording from the response “The Trust accepts that it should have made every effort to feedback the findings of the internal investigation to the agency irrespective of whether the midwife was continuing to work for the Trust. The Trust have processes in place for providing feedback to agencies and we are now doing this in all situations. We are also strengthening the policy around reporting concerns in situations where staff no longer work at the Trust, and ensuring that the Policy is explicit in its requirement to do so. The Trust’s learning culture and transparency was recognised by an Ockenden Assurance and Insight visit led by” Source location Response from Royal Berkshire NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A national solution for agency staff standards is a matter for the regulator and wider regional and national organisations.
Verbatim wording from the response “Upon further deliberation and reflection, the Trust considers that this is a matter for the regulator because a national solution is required and this is beyond the means of a single Trust. The Director of Midwifery has raised this with the Regional Chief Midwife, ████████, who has discussed this with the Chief Midwife for England and the NMC. As a result recommendations will be sent to organisations reminding them that serious concerns over practice of an agency member of staff should be referred to the agency and NMC. In addition there are plans in place to convene a group including providers, LMNS, region and Health Education England to ensure there is a standardised approach to the orientation and immediate support provided to agency staff.” Source location Response from Royal Berkshire NHS Foundation Trust
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Concerns raised 1
Failure to make timely referrals of concerns about individual professional capabilities and practice to relevant professional bodies 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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Brian Rochell · 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
Brian Rochell was admitted to hospital on 10 April 2019 for surgery related to tongue cancer. He died on 26 April 2019 after an unsuccessful extubation caused a hypoxic brain injury. The principal concerns were that the extubation decision was made without adequate risk assessment, concerns from clinicians were given insufficient weight, and there was no clear plan for reintubation. The report also raised concerns about timely referral of professional practice concerns to the relevant professional body.
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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 make timely referrals of concerns about individual professional capabilities and practice to relevant professional bodies
Wider context from the report “(1) I heard that there were concerns about individual practice in this case and that the result of that was an informal conversation with the relevant professional body and agreed steps being taken to moderate practice until the conclusion of the inquest. Where there are concerns about the professional capabilities and practices of a particular individual these should be addressed with the relevant professional body at the earliest opportunity by the employer. There may be cases where there will not be a coroner’s investigation and the purpose of a coroner’s investigation is not to assess the competence of professionals but rather to investigate the circumstances of the death. This means that where practice should be reviewed by professional bodies, failure to make appropriate referrals in a timely fashion could place other patients at risk in the future.
” Source location Brian Rochell · Prevention of Future Deaths report
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26 Mar 2021 Rachel Bernadette Johnston · Prevention of Future Deaths report Worcestershire
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Concerns raised 4
Failure to prevent nursing staff from working at Pirton Grange again when appropriate after investigation View source Failure to identify and investigate possible misconduct by nursing staff View source Failure to impose interim suspension of nursing staff where needed to protect residents View source
Failure to report likely nursing staff misconduct to the NMC View source See 1 more concern
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Rachel Bernadette Johnston · 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
Rachel Bernadette Johnston, who had significant physical and learning disabilities, underwent dental surgery and was discharged to Pirton Grange Nursing Home, where she developed aspiration pneumonia and an unsurvivable hypoxic brain injury. She died there on 13 November 2018. The principal concerns were inadequate physiological observations and failure to seek emergency medical assistance, followed by inadequate internal investigation and disciplinary procedures concerning the nurses involved, including delayed reporting to the NMC.
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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 prevent nursing staff from working at Pirton Grange again when appropriate after investigation
Wider context from the report “(1) Following Rachel’s death, there appears to have been no adequate internal investigation or disciplinary procedure which was able to identify the gross failings of the nurses mentioned above. Accordingly, both nurses continued working at Pirton Grange for some time, without any action being taken to ensure that patients were not put at risk by their actions. Furthermore, no effort was made to report the conduct of the nurses concerned to the Nursing and Midwifery Council ( NMC ), the appropriate regulatory body, until February 2021, over 2 years after Rachel’s death;
(2) Even now, there appears to be no Policy in place at Pirton Grange which sets out a suitable and robust procedure for:
(a) identifying and investigating possible misconduct by nursing staff, e.g. where they have ignored a Policy;
(b) imposing an interim suspension on a member of the nursing staff, pending the completion of such an investigation, if in the interests of ensuring the ongoing safety of residents;
(c) if appropriate after the investigation has been completed, ensuring that member of the nursing staff does not work at Pirton Grange again ; and
(d) if the internal investigation has identified likely misconduct, reporting that member of the nursing staff to the NMC.
” Source location Rachel Bernadette Johnston · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify and investigate possible misconduct by nursing staff
Wider context from the report “(1) Following Rachel’s death, there appears to have been no adequate internal investigation or disciplinary procedure which was able to identify the gross failings of the nurses mentioned above . Accordingly, both nurses continued working at Pirton Grange for some time, without any action being taken to ensure that patients were not put at risk by their actions. Furthermore, no effort was made to report the conduct of the nurses concerned to the Nursing and Midwifery Council ( NMC ), the appropriate regulatory body, until February 2021, over 2 years after Rachel’s death;
(2) Even now, there appears to be no Policy in place at Pirton Grange which sets out a suitable and robust procedure for:
(a) identifying and investigating possible misconduct by nursing staff, e.g. where they have ignored a Policy ;
(b) imposing an interim suspension on a member of the nursing staff, pending the completion of such an investigation, if in the interests of ensuring the ongoing safety of residents;
(c) if appropriate after the investigation has been completed, ensuring that member of the nursing staff does not work at Pirton Grange again; and
(d) if the internal investigation has identified likely misconduct, reporting that member of the nursing staff to the NMC.
” Source location Rachel Bernadette Johnston · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to impose interim suspension of nursing staff where needed to protect residents
Wider context from the report “(1) Following Rachel’s death, there appears to have been no adequate internal investigation or disciplinary procedure which was able to identify the gross failings of the nurses mentioned above. Accordingly, both nurses continued working at Pirton Grange for some time, without any action being taken to ensure that patients were not put at risk by their actions . Furthermore, no effort was made to report the conduct of the nurses concerned to the Nursing and Midwifery Council ( NMC ), the appropriate regulatory body, until February 2021, over 2 years after Rachel’s death;
(2) Even now, there appears to be no Policy in place at Pirton Grange which sets out a suitable and robust procedure for:
(a) identifying and investigating possible misconduct by nursing staff, e.g. where they have ignored a Policy;
(b) imposing an interim suspension on a member of the nursing staff, pending the completion of such an investigation, if in the interests of ensuring the ongoing safety of residents ;
(c) if appropriate after the investigation has been completed, ensuring that member of the nursing staff does not work at Pirton Grange again; and
(d) if the internal investigation has identified likely misconduct, reporting that member of the nursing staff to the NMC.
” Source location Rachel Bernadette Johnston · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to report likely nursing staff misconduct to the NMC
Wider context from the report “(1) Following Rachel’s death, there appears to have been no adequate internal investigation or disciplinary procedure which was able to identify the gross failings of the nurses mentioned above. Accordingly, both nurses continued working at Pirton Grange for some time, without any action being taken to ensure that patients were not put at risk by their actions. Furthermore, no effort was made to report the conduct of the nurses concerned to the Nursing and Midwifery Council ( NMC ), the appropriate regulatory body, until February 2021, over 2 years after Rachel’s death ;
(2) Even now, there appears to be no Policy in place at Pirton Grange which sets out a suitable and robust procedure for:
(a) identifying and investigating possible misconduct by nursing staff, e.g. where they have ignored a Policy;
(b) imposing an interim suspension on a member of the nursing staff, pending the completion of such an investigation, if in the interests of ensuring the ongoing safety of residents;
(c) if appropriate after the investigation has been completed, ensuring that member of the nursing staff does not work at Pirton Grange again; and
(d) if the internal investigation has identified likely misconduct, reporting that member of the nursing staff to the NMC .
” Source location Rachel Bernadette Johnston · Prevention of Future Deaths report
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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 Establish independent solicitor oversight for staff misconduct investigations, disciplinary matters and professional-body referrals.
Verbatim wording from the response “As a result of the HM Coroners concerns the Home has made its procedures more robust. This includes independent oversight to identify and investigate possible misconduct by staff, including nursing staff. This comprises of the engagement of a Solicitor’s firm on a retainer basis to provide general employment advice, support on all HR matters and assistance and oversight with and/or advising on any investigation, disciplinary matters, and considering whether any reports to professional bodies should be made. The Home will engage its Solicitors at the very outset where there is an issue which may give rise to any misconduct issues by staff.” Source location 2021-0090-Response-from-Holmleigh-Care-Homes-Ltd-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 Engage retained solicitors at the outset of issues that may involve staff misconduct.
Verbatim wording from the response “As a result of the HM Coroners concerns the Home has made its procedures more robust. This includes independent oversight to identify and investigate possible misconduct by staff, including nursing staff. This comprises of the engagement of a Solicitor’s firm on a retainer basis to provide general employment advice, support on all HR matters and assistance and oversight with and/or advising on any investigation, disciplinary matters, and considering whether any reports to professional bodies should be made. The Home will engage its Solicitors at the very outset where there is an issue which may give rise to any misconduct issues by staff.” Source location 2021-0090-Response-from-Holmleigh-Care-Homes-Ltd-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing procedures, policies, oversight and training are considered sufficient to address the concerns and identify failures posing risks to service-user safety.
Verbatim wording from the response “As a result of the HM Coroners concerns the Home has made its procedures more robust. This includes independent oversight to identify and investigate possible misconduct by staff, including nursing staff. This comprises of the engagement of a Solicitor’s firm on a retainer basis to provide general employment advice, support on all HR matters and assistance and oversight with and/or advising on any investigation, disciplinary matters, and considering whether any reports to professional bodies should be made. The Home will engage its Solicitors at the very outset where there is an issue which may give rise to any misconduct issues by staff.” Source location 2021-0090-Response-from-Holmleigh-Care-Homes-Ltd-Redacted
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20 Mar 2018 Peter O’Donnell · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Failure to mandate prompt reporting of nurses’ professional misconduct to the Nursing and Midwifery Council View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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Peter O’Donnell · 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
Peter O’Donnell was admitted for an elective right total hip replacement and later developed a chest infection and deteriorated. The report identifies concerns about ineffective communication, irregular observations, inadequate documentation, delayed antibiotics, missed opportunities to escalate care, unclear consultant and junior doctor arrangements, and the absence of transfer protocols for unwell patients. It also raises concerns about private hospitals’ reporting requirements and the reporting of nurses’ retrospective additions to clinical records.
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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 mandate prompt reporting of nurses’ professional misconduct to the Nursing and Midwifery Council
Wider context from the report “5. Following Mr O’Donnell’s death BMI Healthcare on behalf of the Beaumont Hospital instigated a root cause analysis investigation in the course of which it became clear that two registered General Nurses who were involved in the care afforded to Mr O’Donnell made a number of additions to both the observations chart and nursing notes after Mr O’Donnell had been transferred to the acute Hospital in direct contravention of Clause 10.3 within the Code detailing professional standards of practice and behaviour for Nurses and Midwives issued in 2015.
Whilst the BMA instigated its own independent disciplinary investigation I believe that the Nurse’s actions should have been reported forthwith to the Nursing and Midwifery Council as I believe it would be the case in the public sector. Reporting should be mandatory in the private hospital sector .
” Source location Peter O’Donnell · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The employer is responsible for deciding whether to refer registered nurses or midwives to the NMC, subject to mandatory referral circumstances.
Verbatim wording from the response “Finally, with regard to your last area of concern, pertaining to the referral of registered nurses to the NMC, I can confirm that the NMC’s guidance applies to all employers of nurses and midwives, whether NHS or independent sector. It is for the employer to decide whether to make a referral based on the circumstances of the case. Referrals must always be made if the employer believes the conduct competence, health or character of a nurse or midwife” Source location 2018-0201-Response-by-Department-of-Health
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6 Mar 2015 Thor Harrison Dalhaug · Prevention of Future Deaths report Central Lincolnshire
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Concerns raised 1
Failure to discipline clinicians or limit their practice after adoption of an inappropriate delivery technique View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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Thor Harrison Dalhaug · Prevention of Future Deaths report
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Report summary
Thor Dalhaug was delivered by caesarean section on 23 September 2013 in poor condition after difficulties delivering his deeply engaged head, and died approximately one hour after birth. The report identified concerns including lack of supervision of the operating surgeon, use of an inappropriate forceps technique, inadequate contemporaneous records and shortcomings in the internal investigation and disclosure of the circumstances of his death.
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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 discipline clinicians or limit their practice after adoption of an inappropriate delivery technique
Wider context from the report “(II) The lack of any steps having been taken to discipline the clinicians involved or limit their practice given their decision to adopt a wholly inappropriate, unacceptable, and unorthodox technique in delivering Thor, resulting in his death.
” Source location Thor Harrison Dalhaug · Prevention of Future Deaths report
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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 Implement the comprehensive junior-doctor obstetrics and gynaecology induction programme, including orientation, competency assessments, guidance access, support contacts, follow-up and supernumerary work.
Verbatim wording from the response “As indicated in the evidence heard at inquest, the Trust has now taken various steps to significantly reduce the chance of such a situation occurring again. In particular, all junior doctors will now:-” Source location 2015-0063-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust did not consider it appropriate to single out or blame an individual, preferring wider analysis of working systems and processes.
Verbatim wording from the response “Matters relating to disciplinary proceedings are confidential between the employee and employer. The Trust would, however, like to offer you assurance that appropriate management action has been taken including liaison with the relevant regulatory authorities. The Trust would also like to make it clear that whilst it acknowledges that the forceps delivery should not have been attempted, it did not feel it appropriate to single out or blame any individual for the tragic events that occurred that day during delivery. The Trust wished to analyse the wider context” Source location 2015-0063-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust could not discuss disciplinary proceedings because they were confidential matters between employee and employer.
Verbatim wording from the response “As discussed at response 2 above the Trust is advised that it would not be appropriate to discuss any disciplinary proceedings.” Source location 2015-0063-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.