21 Dec 2016 David Bassett COOPER · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Lack of comprehensive transfer handover of falls risk 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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David Bassett COOPER · 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
David Bassett Cooper was admitted to hospital after a serious head injury caused by a fall in the community and sustained nine further falls while being transferred between wards. He died from a subdural haematoma caused by the final fall on 5 March 2016. The concerns included inadequate handovers about falls risk, incomplete nursing records, a failure to see the overall pattern of falls, and shortcomings in arranging additional one-to-one nursing 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 Lack of comprehensive transfer handover of falls risk
Wider context from the report “1. When transfers between wards took place, the evidence revealed that there was a lack of comprehensive hand-over by the transferring ward to the receiving ward especially in terms of identifying the patient’s risk of falls . For example, on ward 18 Mr Cooper was in receipt of ‘1:1’ nursing care, but on transfer to ward 21, not only was that never given, but the evidence suggested it was not considered.
” Source location David Bassett COOPER · Prevention of Future Deaths report
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Concerns raised 1
Failure to implement consultants' requests for patient transfer to specialist wards View source
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Christopher Allen MacMORLAND · Prevention of Future Deaths report
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Report summary
Christopher Allen MacMORLAND was admitted to hospital with feeding difficulties and later readmitted with abdominal pain and distension; his condition deteriorated and he died on 5 December 2015. The substantive concern was that, despite five requests by consultant gastroenterologists, he was not transferred to a specialist gastroenterology ward, and evidence indicated that such a ward might have affected the outcome.
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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 implement consultants' requests for patient transfer to specialist wards
Wider context from the report “I was told in evidence at the Inquest that despite Mr MacMORLAND being under the care of consultant gastroenterologists during his final admission to hospital he was at no time treated in a specialist gastroenterology ward - even though the consultants had during that time requested such a transfer on five separate occasions . Given the nature of his medical problems, from the evidence I heard, I am of the opinion that he could have benefited from the expertise and facilities available in a gastroenterology ward which might have had an effect on the outcome. I was also told that it is common for consultants' requests for patient transfer to specialist wards not to be implemented .
” Source location Christopher Allen MacMORLAND · 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 Implement a buddy ward system to cohort specialty patients in their appropriate specialist or designated buddy ward.
Verbatim wording from the response “By way of further assurance, since this death in 2015, the Hospital has begun a ‘buddy’ ward system whereby patients of a certain specialty are cohorted only into the appropriate specialist ward or a specific buddy ward. This means that consultants will have their patients only on one other ward if their own base ward is full.” Source location 2016-0415-Response-by-Portsmouth-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 Care was not compromised because the surgical ward staff were familiar with medical gastrointestinal disorders.
Verbatim wording from the response “The patient had had a surgical procedure in the previous month and hence was on the specialist UGI surgical ward and was admitted under the care of the UGI Surgeon. The staff on the Gastrointestinal Surgical ward would have been familiar with medical gastrointestinal disorders and thus we do not believe care was in any way compromised.” Source location 2016-0415-Response-by-Portsmouth-Hospitals-NHS-Trust
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28 Oct 2016 Barbara Turner · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 4
Failure to provide resuscitation equipment and drugs for medical emergencies during transfer View source Failure to provide appropriate vital signs monitoring during transfer to and from the CT scanner View source Failure to provide appropriately qualified clinical escort during transfer to and from the CT scanner View source
Failure to provide equipment and drugs to protect and manage the airway during transfer View source See 1 more concern
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Barbara Turner · 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 Turner, an 81-year-old woman, was admitted for an elective left total knee replacement and was later found unresponsive. She underwent a CT scan and was admitted to intensive care, where she died on 11 May 2015. The report identified concerns about resuscitation-call criteria, failures to recognise and respond to her critical illness, missed vital-sign observations, and the unsafe arrangements for transporting her to and from the CT scanner.
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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 provide resuscitation equipment and drugs for medical emergencies during transfer
Wider context from the report “(2) The method by which Mrs Turner was conveyed to the CT Scanner and back to the ward was described by the ITU consultant, who gave evidence, as ‘dangerous.’ He stated that at the very least Mrs Turner should have been escorted by an anaesthetist and ODA, with appropriate vital signs monitoring and resuscitation equipment and drugs to deal with any medical emergency en route and equipment and drugs to protect and manage her airway.
” Source location Barbara Turner · 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 provide appropriate vital signs monitoring during transfer to and from the CT scanner
Wider context from the report “(2) The method by which Mrs Turner was conveyed to the CT Scanner and back to the ward was described by the ITU consultant, who gave evidence, as ‘dangerous.’ He stated that at the very least Mrs Turner should have been escorted by an anaesthetist and ODA, with appropriate vital signs monitoring and resuscitation equipment and drugs to deal with any medical emergency en route and equipment and drugs to protect and manage her airway.
” Source location Barbara Turner · 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 provide appropriately qualified clinical escort during transfer to and from the CT scanner
Wider context from the report “(2) The method by which Mrs Turner was conveyed to the CT Scanner and back to the ward was described by the ITU consultant, who gave evidence, as ‘dangerous.’ He stated that at the very least Mrs Turner should have been escorted by an anaesthetist and ODA , with appropriate vital signs monitoring and resuscitation equipment and drugs to deal with any medical emergency en route and equipment and drugs to protect and manage her airway.
” Source location Barbara Turner · 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 provide equipment and drugs to protect and manage the airway during transfer
Wider context from the report “(2) The method by which Mrs Turner was conveyed to the CT Scanner and back to the ward was described by the ITU consultant, who gave evidence, as ‘dangerous.’ He stated that at the very least Mrs Turner should have been escorted by an anaesthetist and ODA, with appropriate vital signs monitoring and resuscitation equipment and drugs to deal with any medical emergency en route and equipment and drugs to protect and manage her airway .
” Source location Barbara Turner · Prevention of Future Deaths report
Open source report
28 Oct 2016 Leslie Isaac LERNER · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Failure to provide proper handover during ward transfer View source
This report raised 17 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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Leslie Isaac LERNER · 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
Leslie Isaac Lerner died on 3 June 2016 after treatment for a fractured shoulder, including application of an incorrect sling that caused a deep pressure sore and additional pain. The report identified concerns about inadequate senior review, analgesia, communication, handover, continuity of care, recognition of pneumonia and deterioration, and delay in initiating end-of-life 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 Failure to provide proper handover during ward transfer
Wider context from the report “16th May 2016
(1) Having been admitted to a renal ward, because of lack of beds elsewhere, a member of the medical staff had a telephone discussion with a member of the Orthopaedic Team and a collar and cuff sling was recommended. This information was not passed onto the Nursing Staff, not properly documented nor was the Patient actually seen by a member of Orthopaedic Team. He should have been seen and a note should have been made.
(2) He then was moved to another ward, again not an Orthopaedic Ward, where any chance of correct hand over seems to have been lost because he was transferred to Baily Ward in the middle of the night. No proper handover .
There was no referral to physiotherapists and yet the Trusts own paperwork says that exercises should be given by a Physiotherapist and commenced by the patient after seventy two hours of the fracture occurring. No speedy referral to physiotherapists.
Within his notes was an utterly inadequate document explaining what the Patient needs to do with a fractured shoulder, however, as the Ward Manager pointed out it does not say what type of sling should be applied for this particular Patient and so she apparently had no idea anything was amiss. This document was not fit for purpose either for the patient or the ward.
” Source location Leslie Isaac LERNER · Prevention of Future Deaths report
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13 Oct 2016 Robert Arthur Davidson · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to highlight essential patient information during transfers between care homes View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Avery Healthcare Group Care Quality Commission NHS England Priory Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Avery Healthcare Group
Implement an additional action plan and timetable responding to the inquest findings.
View source
Avery Healthcare Group
Continue embedding all organisational policies and procedures at Aran Court.
View source
Care Quality Commission
Inspect care homes’ emergency response, staff training, induction, and transfer-risk arrangements, including follow-up checks against the reported concerns.
View source
Priory Group
Raise the transfer and discharge communication lessons from the incident in a forthcoming quarterly Safety 1st bulletin shared across Amore Care Homes.
View source
Priory Group
Highlight to home staff the requirement to complete Form AM32 Transfer Discharge records, including prompts for key information such as PCA behaviour.
View source See 2 more actions
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Robert Arthur Davidson · 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 Arthur Davidson, who had dementia, Alzheimer’s disease and PICA, died after choking on a plastic glove at a care home on 27 January 2016. The report identified concerns about inadequate transfer of information about his PICA, insufficient staff training and failures in emergency procedures, including calling emergency services and initiating CPR.
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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 highlight essential patient information during transfers between care homes
Wider context from the report “3. The deceased PICA behaviour was not highlighted or identified on his transfer between care homes. Some process or direction from the governing body needs to be provided to care homes to ensure essential information is provided and highlighted when patients are transferred.
” Source location Robert Arthur Davidson · 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 Implement an additional action plan and timetable responding to the inquest findings.
Verbatim wording from the response “Unfortunately, whilst under the Restful Homes Group tenure, Aran Court had very few of these processes in place and where systems or processes were in situ they were often substandard. It remains an ongoing process to fully embed all of Avery’s policies and procedures and in light of the inquests findings an additional action plan and timetable for action has been implemented.” Source location 2016-0363-Response-by-Avery
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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 Continue embedding all organisational policies and procedures at Aran Court.
Verbatim wording from the response “Unfortunately, whilst under the Restful Homes Group tenure, Aran Court had very few of these processes in place and where systems or processes were in situ they were often substandard. It remains an ongoing process to fully embed all of Avery’s policies and procedures and in light of the inquests findings an additional action plan and timetable for action has been implemented.” Source location 2016-0363-Response-by-Avery
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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 Inspect care homes’ emergency response, staff training, induction, and transfer-risk arrangements, including follow-up checks against the reported concerns.
Verbatim wording from the response “During the course of the CQC focused inspection of Aran Court Care Centre on 09 March 2016, we found systems in place to ensure that nurses had training in emergency first aid. Emergency First Aid at work training provides delegates with an extensive first aid skill set so that they can identify incidents and manage them appropriately, whether the patient is conscious or unconscious. The course is designed to include first aid priorities, managing incidents, basic life support (CPR), unconsciousness, control of bleeding, burns and scolds, recording and reporting First Aid Priorities.” Source location 2016-0363-Response-by-Care-Quality-Commission
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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 Raise the transfer and discharge communication lessons from the incident in a forthcoming quarterly Safety 1st bulletin shared across Amore Care Homes.
Verbatim wording from the response “• This incident and the lessons learnt from it i.e. to ensure effective communication at the point of a resident’s transfer or discharge to another provider will be raised in a forthcoming issue of our quarterly Safety 1st bulletin which is shared across all of our Amore Care Homes.” Source location 2016-0363-Response-by-Priory-Group
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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 Highlight to home staff the requirement to complete Form AM32 Transfer Discharge records, including prompts for key information such as PCA behaviour.
Verbatim wording from the response “• We will also highlight the requirement for our home staff to complete Form AM32 Transfer Discharge record. This form is completed in accordance with Policy AM27 Admission, Transfer and Discharge (July 2016). The form contains prompts for staff to record key information such as PCA behaviour. The completed form is then provided to staff at the receiving organisation at the point of the resident’s transfer or discharge.” Source location 2016-0363-Response-by-Priory-Group
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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 Comprehensive pre-admission and transfer documentation is considered sufficient to identify relevant clinical risks when completed correctly.
Verbatim wording from the response “As a provider Avery Healthcare does have appropriate systems and documentation in situ to address each of the above points.” Source location 2016-0363-Response-by-Avery
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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 admission and handover documents were considered sufficient to capture known risks during transfers when completed appropriately.
Verbatim wording from the response “CQC expects that providers should actively work with others, both internal and external, to make sure the care and treatment remains safe for people using the service. When people move between services or providers, Regulation 12(2) (The Regulations) requires providers to undertake appropriate risk assessments to make sure service users’ safety is not compromised. This includes when they move between or to other bodies who may not be registered with CQC. At the inspection on 14 November 2016 at Aran Court Care Centre, we looked at Avery Homes RH Limited’s admission assessment document. This is the provider’s transfer document. Whilst we did not look specifically at Mr Davidson’s transfer document, we saw that if this admission document was completed appropriately and with sufficient detail, the information needed to ensure that where people were known to be at risk would be captured.” Source location 2016-0363-Response-by-Care-Quality-Commission
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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 System-wide direction on identifying essential transfer information is directed to the governing body, such as the regulator or relevant health department.
Verbatim wording from the response “Whilst we understand that you have directed this matter of concern to be dealt with by the governing body (which we take to understand either the regulator the Care Quality Commission or the Department of Health or NHS England) we hope that you will be reassured by the actions that we intend to take in respect of this matter.” Source location 2016-0363-Response-by-Priory-Group
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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 commissioning organisation should ensure receiving care homes can meet transferred patients’ needs; the Care Quality Commission may comment on this.
Verbatim wording from the response “It is essential that information is communicated between organisations when a patient is transferred. In this case between Jubilee Gardens and Aran Court Care Centre. Had Aran Court Care Centre been aware of Mr Davidson’s condition they would have been aware of the need for additional, possibly 1:1, care. The commissioning organisation should be satisfied that the organisation to which Mr Davidson was being admitted were able to meet his care needs. The care home will be registered with and regulated by the Care Quality Commission, to whom this Regulation 28 report has also been sent, and they may wish to comment in respect of this issue.” Source location 2016-0363-Response-by-NHS-England
Open published response
3 Aug 2016 Winston Harris · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2
Failure to communicate absconding risk in written hospital transfer documentation View source Failure to provide written confirmation of DOLS applications during hospital transfer 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
Winston Harris · 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
Winston Harris, a resident with dementia, left hospital on 17 March 2016 after previously attempting to leave the ward. He was found at a bus stop the following day, severely hypothermic with an acute kidney injury, and died on 22 March 2016; the inquest concluded that he died from dilated cardiomyopathy contributed to by hypothermia and acute kidney injury. Concerns included inadequate documentation of his absconding risk and pending deprivation of liberty application, failure to consider an emergency deprivation of liberty safeguard, and delays in processing the application.
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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 communicate absconding risk in written hospital transfer documentation
Wider context from the report “(2)When Mr Harris was transferred to hospital, without an escort, there was no written documentation provided to confirm that a DOLS had been applied for and that he was an absconding risk .
” Source location Winston Harris · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide written confirmation of DOLS applications during hospital transfer
Wider context from the report “(2)When Mr Harris was transferred to hospital, without an escort, there was no written documentation provided to confirm that a DOLS had been applied for and that he was an absconding risk.
” Source location Winston Harris · Prevention of Future Deaths report
Open source report
28 Jun 2016 David Michael little · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to keep clear records of inpatient radiology transfers, purposes, procedures and ward returns View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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David Michael little · 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
David Michael Little was admitted to hospital with abdominal pain and a suspected small-bowel mass. His condition worsened, and a scan revealed a blockage caused by ischaemic bowel; delays in scanning, reporting, and insertion of an NG tube meant that surgery was considered when it was deemed too late. The report raised concerns about poor record-keeping, lack of a clear diagnostic and monitoring pathway, failure to recognise the seriousness of bowel obstruction, and poor communication among staff and with the family.
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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 keep clear records of inpatient radiology transfers, purposes, procedures and ward returns
Wider context from the report “1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the procedure had been carried out, whether the patient had been returned to the ward . In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient, and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day.
” Source location David Michael little · 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 Implement the Radiology Requesting and Reporting Policy requiring documentation of radiology discussions, appointment changes and communication with responsible clinicians.
Verbatim wording from the response “Following Mr Little’s death, the department has published a ‘Radiology Requesting and Reporting Policy’ in February 2016 (Document 1 attached). The Policy requires the clinician to document the discussion in the clinical notes of the request made to Radiology and the response given. Once the scan is requested, the Radiology department must then ensure that they document any changes to the planned appointment and communicate them with the responsible clinician. It is clear that at the time of Mr Little’s death, the communication appeared to be confusing and there are insufficient documented records to confirm what conversations actually took place at the time.” Source location 2016-0237-Response-by-Tameside-Hospital-NHS-Trust
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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 Develop and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.
Verbatim wording from the response “In addition, there is currently a documented tracking/handover policy in draft (Document 2 attached) which will document any specific requests that are given to the patient via the ward staff to prepare them for their investigation, e.g. nil by mouth or the requirement for a full bladder. It will include a feedback form that the porter will take to the ward when collecting the patient for a member of the nursing staff to sign to confirm the patient’s identification and the test/imaging the patient is scheduled for. On return of the patient to the ward, the sheet will document what investigation has taken place and any special observations required. This form will form a part of the radiology record and be filed in the patient’s notes.” Source location 2016-0237-Response-by-Tameside-Hospital-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 patient was not taken to radiology by mistake; Radiology records show his scan was scheduled and expected that day.
Verbatim wording from the response “1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the patient had been returned to the ward. In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient, and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day.” Source location 2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Open published response
Concerns raised 1
Absence of a robust system for conveying summary medical information to receiving A&E departments during acute illness transfers View source
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Anthony Benjamin Patrick Fraser · 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
Anthony Benjamin Patrick Fraser had terminal multiple myeloma and died at Doncaster Royal Infirmary on 24 September 2015 after his condition significantly progressed and palliative care was initiated. The report identified the absence of a robust system for conveying summary medical information to receiving A&E departments when inmates are transferred with an acute illness, which could delay diagnosis for other inmates.
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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 Absence of a robust system for conveying summary medical information to receiving A&E departments during acute illness transfers
Wider context from the report “I heard evidence that the medical records on the electronic Spine One contain a summary overview of a person’s medical status which should be sent to A&E Departments where patients have been referred. This information is readily accessible but in Mr Fraser’s case when he was referred to A&E on 15th August 2015, this information was not conveyed by them to the receiving hospital. I also heard in evidence that there is no system for ensuring that such information is sent and therefore is “hit and miss” as to whether or not it is sent . Whilst I concluded that in Mr Fraser’s case this did not affect the ultimate outcome due to him re-attending four days later and given the very aggressive nature of the cancer from which he was suffering, it is clear that for other inmates with different conditions, failure to provide such information may well delay diagnosis or make it extremely difficult to reach diagnosis . Accordingly consideration needs to be given to implementing a system where such information is conveyed for every such inmate in a timely fashion.
Summary of concerns:-
1. Absence of a robust system for conveying summary medical information to receiving A&E departments when inmates are transferred with an acute illness. .
” Source location Anthony Benjamin Patrick Fraser · 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 Implement a jointly authored procedure defining custodial and healthcare responsibilities for conveying summary medical information to receiving A&E departments.
Verbatim wording from the response “Following the receipt of the Regulation 28 Report, a collaborative meeting took place with the Governor of HMP Lindholme, ████████ and the Associate Director for Offender Health, ████████ and the Head of Healthcare at HMP Lindholme, ████████ and the Head of Security at HMP Lindholme, ████████. The purpose of the meeting was to develop a shared system to address the concerns you have raised in the Preventing Future Deaths report.” Source location 2016-0225-Response-by-Nottinghamshire-Healthcare-NHS-Trust
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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 Undertake a compliance review of the information-transfer procedure to confirm full implementation of the system.
Verbatim wording from the response “A procedure was co-authored by the group, clearly identifying the roles and responsibilities of both Custodial and Healthcare staff. A copy of the procedure has been included with this letter. The procedure has been issued to staff and is now in operation. A review of compliance will be undertaken by the Head of Healthcare within the coming month, to ensure we have achieved full implementation for a robust system of conveying summary medical information to A&E depts.” Source location 2016-0225-Response-by-Nottinghamshire-Healthcare-NHS-Trust
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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 Share the information-transfer procedure at the Offender Health Learning the Lessons Forum to support adoption by other establishments.
Verbatim wording from the response “A copy of the procedure will be shared at the Offender Health Learning the Lessons Forum on the 9th of September 2016, to ensure colleagues in other establishments also have a system in place for the transfer of medical information, thereby avoiding future deaths.” Source location 2016-0225-Response-by-Nottinghamshire-Healthcare-NHS-Trust
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23 Mar 2016 June Elsie Parkes · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 1
Lack of criteria for doctor presence during ambulance transfer of critically ill patients View source
This report raised 10 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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June Elsie Parkes · 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
June Elsie Parkes became unwell with symptoms of an upper gastrointestinal bleed and was admitted to hospital on 14 December 2014. She later deteriorated and died shortly after being transferred to Huddersfield Royal Infirmary on 17 December 2014. The concerns included delays and gaps in systems for urgent or emergency endoscopy and surgery, monitoring and escalation, record keeping, and the transfer of critically ill patients.
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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 criteria for doctor presence during ambulance transfer of critically ill patients
Wider context from the report “(7) The criteria for when a doctor should be present during ambulance transfer between Calderdale Royal Hospital and Huddersfield Royal Infirmary of a critically ill patient
” Source location June Elsie Parkes · Prevention of Future Deaths report
Open source report
17 Feb 2016 Matthew Crowley · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure to inform the receiving ITU of patient transfers View source
This report raised 5 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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Matthew Crowley · 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
Matthew Crowley, aged 39, presented to Maidstone Hospital acutely unwell with sepsis and multiple organ failure, and died at Pembury Hospital at 06.47 on 10 June 2015 after transfer. The report identified concerns including delays in triage, senior medical review, treatment escalation, decision-making and transfer, as well as inadequate communication with the receiving ITU.
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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 inform the receiving ITU of patient transfers
Wider context from the report “(5) The ITU of the hospital to which the patient was transferred were not informed of the transfer
” Source location Matthew Crowley · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.