Concerns raised 3
Failure to reliably identify matters requiring investigation View source Lack of defined and consistently applied criteria for identifying and acting on learning opportunities View source Failure to ensure timely learning and action from investigations View source
This report raised 2 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
Kate Louise Pierce · 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
Kate Louise Pierce became unwell on 29 March 2006 and was discharged from hospital after being diagnosed with viral tonsillitis. She returned approximately 36 hours later in a deteriorated condition, was diagnosed with pneumococcal meningitis, and later died in Florida on 19 March 2013 after suffering brain damage and other health conditions. The principal concerns were uncertainty about when a sick child should receive senior paediatric assessment before discharge, and a lack of clearly defined and consistently applied processes for identifying and acting on learning opportunities after adverse events or re-presentation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to reliably identify matters requiring investigation
Wider context from the report “(2) I heard evidence at length from the Health Board’s current Clinical Lead for Paediatrics about (inter alia) the measures which are in place to ensure that lessons can be learnt (and acted upon) promptly when things do not go to plan. Specifically I heard about steps taken to learn lessons from situations in which a child might re-present in a worse condition following an earlier discharge – a situation which might result from a missed diagnosis. I did not emerge from this evidence with any confidence that there exist clearly defined and consistently applied criteria from ensuring that learning opportunities are being actively sought out and acted upon. For example, I was told that there is no defined list of triggers; with much left to judgement of individuals in the senior management team. This evidence, supplemented by the relevant contents of the letter of 4 October 2017, leaves me concerned that too much is left to chance in the identification of matters requiring investigation ; in the selection of staff and in the urgency of lessons being learnt and acted upon. The current system might therefore warrant a review (perhaps including consideration of best practice elsewhere, in other hospitals outside the Health Board) to see whether grounds for improvement exist.
” Source location Kate Louise Pierce · 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 Lack of defined and consistently applied criteria for identifying and acting on learning opportunities
Wider context from the report “(2) I heard evidence at length from the Health Board’s current Clinical Lead for Paediatrics about (inter alia) the measures which are in place to ensure that lessons can be learnt (and acted upon) promptly when things do not go to plan. Specifically I heard about steps taken to learn lessons from situations in which a child might re-present in a worse condition following an earlier discharge – a situation which might result from a missed diagnosis. I did not emerge from this evidence with any confidence that there exist clearly defined and consistently applied criteria from ensuring that learning opportunities are being actively sought out and acted upon . For example, I was told that there is no defined list of triggers ; with much left to judgement of individuals in the senior management team. This evidence, supplemented by the relevant contents of the letter of 4 October 2017, leaves me concerned that too much is left to chance in the identification of matters requiring investigation; in the selection of staff and in the urgency of lessons being learnt and acted upon. The current system might therefore warrant a review (perhaps including consideration of best practice elsewhere, in other hospitals outside the Health Board) to see whether grounds for improvement exist.
” Source location Kate Louise Pierce · 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 ensure timely learning and action from investigations
Wider context from the report “(2) I heard evidence at length from the Health Board’s current Clinical Lead for Paediatrics about (inter alia) the measures which are in place to ensure that lessons can be learnt (and acted upon) promptly when things do not go to plan. Specifically I heard about steps taken to learn lessons from situations in which a child might re-present in a worse condition following an earlier discharge – a situation which might result from a missed diagnosis. I did not emerge from this evidence with any confidence that there exist clearly defined and consistently applied criteria from ensuring that learning opportunities are being actively sought out and acted upon. For example, I was told that there is no defined list of triggers; with much left to judgement of individuals in the senior management team. This evidence, supplemented by the relevant contents of the letter of 4 October 2017, leaves me concerned that too much is left to chance in the identification of matters requiring investigation; in the selection of staff and in the urgency of lessons being learnt and acted upon. The current system might therefore warrant a review (perhaps including consideration of best practice elsewhere, in other hospitals outside the Health Board) to see whether grounds for improvement exist.
” Source location Kate Louise Pierce · Prevention of Future Deaths report
Open source report
7 Sep 2017 Glenys Pollitt · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of an ongoing programme for reinforcing clinical lessons View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Glenys Pollitt · 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
Glenys Pollitt was admitted to Stepping Hill Hospital with community acquired pneumonia, but surgical emphysema and an oesophageal rupture were not identified on an initial x-ray and subsequent reviews. She underwent emergency surgery after the rupture was identified, deteriorated, and died from multi-organ failure on 16 February 2017. Concerns included inconsistent use of high-resolution x-ray screens, unclear reinforcement of clinical learning, and unclear escalation processes to consultant and critical care levels.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of an ongoing programme for reinforcing clinical lessons
Wider context from the report “2. At the inquest, the evidence given was that the clinicians had seen what they expected to see on the x ray rather than seeing the whole picture shown on the x ray. It was unclear what ongoing programme was in place for reinforcing the lessons learnt from this case amongst clinicians ;
” Source location Glenys Pollitt · Prevention of Future Deaths report
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 Complete morbidity and mortality discussions in Emergency Department and Acute Medicine to share and learn from the case.
Verbatim wording from the response “Both the Emergency Department team and the Acute Medicine team have completed morbidity & mortality discussions regarding this case – completed on 15/02/2017 and 24/05/2017 respectively. These are perfect opportunities for cases to be shared with clinicians across all grades to review and learn from a case.” Source location 2017-0228-Response-by-Stockport-NHS-Trust
Open published response
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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 Use the case in future training programmes for junior clinical staff in Emergency Department and Acute Medicine.
Verbatim wording from the response “Both departments have confirmed that they intend to use this case for future training of junior clinical staff in their ongoing training programmes.” Source location 2017-0228-Response-by-Stockport-NHS-Trust
Open published response
18 Jan 2017 Michael Parke · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1
Failure to learn from deaths and incidents View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Michael Parke · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Parke, who had chronic liver disease, was admitted to West Cumberland Hospital and had a nasogastric tube inserted. The tube was misplaced into his left lung, an x-ray showing this was misinterpreted, and feeding and medication were administered through the tube before he developed aspiration pneumonia and died. The concerns included staff not following nasogastric-tube policy and systemic failures in policy implementation, training, competency checks, auditing and organisational learning.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to learn from deaths and incidents
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Source location Michael Parke · Prevention of Future Deaths report
Open source 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 Amend regulations to require NHS Trusts to summarise published deaths information, learning and resulting actions in Quality Accounts.
Verbatim wording from the response “We are also amending regulations to require Trusts to summarise the published information in Quality Accounts from June 2018, including evidence of learning and action as a result of that information and an assessment of the impact of actions that a Trust has taken.” Source location 2017-0024-Response
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 Contact the deceased patients’ families to obtain personal comments for organisational learning briefings.
Verbatim wording from the response “I will be reporting this action plan to the public Board meeting in March 2017, please do let me know if you have any concerns regarding this. In addition to this, we are in the process of contacting the families of Michale Parke and Amanda Coulthard in order to include a personal comment from them in the organisational briefings which will be holding in April 2017 to share the learning from these tragic Never Events.” Source location 2017-0025-Response-by-North-Cumbria-University-Hospitals-Trust
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 Hold organisational briefings in April 2017 to share learning from the Never Events.
Verbatim wording from the response “I will be reporting this action plan to the public Board meeting in March 2017, please do let me know if you have any concerns regarding this. In addition to this, we are in the process of contacting the families of Michale Parke and Amanda Coulthard in order to include a personal comment from them in the organisational briefings which will be holding in April 2017 to share the learning from these tragic Never Events.” Source location 2017-0025-Response-by-North-Cumbria-University-Hospitals-Trust
Open published response
18 Jan 2017 Amanda Coulthard · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1
Failure to learn from a prior nasogastric tube death View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Amanda Coulthard · 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
Amanda Coulthard, who had multiple sclerosis, died on 26 April 2015 after a nasogastric tube entered her right lung and feed and medication were administered into it. She developed aspiration pneumonia. The concerns included failures to follow and implement nasogastric-tube policies and best practice, inadequate checking and training, and insufficient systems to ensure compliance and learn from previous deaths.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to learn from a prior nasogastric tube death
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Source location Amanda Coulthard · Prevention of Future Deaths report
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 Amend regulations to require NHS Trusts to summarise published deaths information, learning and resulting actions in Quality Accounts.
Verbatim wording from the response “We are also amending regulations to require Trusts to summarise the published information in Quality Accounts from June 2018, including evidence of learning and action as a result of that information and an assessment of the impact of actions that a Trust has taken.” Source location 2017-0024-Response
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 Contact the deceased patients’ families to obtain personal comments for organisational learning briefings.
Verbatim wording from the response “I will be reporting this action plan to the public Board meeting in March 2017, please do let me know if you have any concerns regarding this. In addition to this, we are in the process of contacting the families of Michale Parke and Amanda Coulthard in order to include a personal comment from them in the organisational briefings which will be holding in April 2017 to share the learning from these tragic Never Events.” Source location 2017-0025-Response-by-North-Cumbria-University-Hospitals-Trust
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 Hold organisational briefings in April 2017 to share learning from the Never Events.
Verbatim wording from the response “I will be reporting this action plan to the public Board meeting in March 2017, please do let me know if you have any concerns regarding this. In addition to this, we are in the process of contacting the families of Michale Parke and Amanda Coulthard in order to include a personal comment from them in the organisational briefings which will be holding in April 2017 to share the learning from these tragic Never Events.” Source location 2017-0025-Response-by-North-Cumbria-University-Hospitals-Trust
Open published response
22 Dec 2016 Demi Williams · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure of investigations to reflect identified risk issues for further learning View source
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.
×
AI-generated summary
Demi Williams · 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
Demi Williams was detained under the Mental Health Act after developing psychotic symptoms and disclosed that she had purchased helium gas intending to kill herself. She was later found deceased in her flat from helium inhalation; the principal concerns were that her specific risk of access to helium was not assessed and that this issue was not reflected in the Trust’s investigation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of investigations to reflect identified risk issues for further learning
Wider context from the report “(1) The method that Ms Williams later used to take her own life was specifically described to CANDI during the assessment process in January 2016. I am concerned that, although a general risk assessment was undertaken on several occasions, there was no consideration of the specific risk which Ms Williams had previously described.
Furthermore, I am concerned that, as it stands, the Trust’s own investigation does not reflect this issue and that the potential for further learning from Ms Williams’ death could be missed .
” Source location Demi Williams · Prevention of Future Deaths report
Open source report
19 Aug 2016 George Watson · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 1
Failure to derive wider organisational learning from investigations 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.
×
AI-generated summary
George Watson · 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
George Watson fell from his bed at approximately 04:30 on 3 September 2014 after being admitted following a fall, and died on 21 October 2014 from a subdural haemorrhage, skull fracture and compound fracture of his left humerus. The principal concerns included supervision and staffing arrangements, raised bed rails, discharge without necessary oral pain relief and inadequate investigatory processes, including cooperation with police inquiries.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to derive wider organisational learning from investigations
Wider context from the report “(4) Although UHCW provided oral evidence regarding some steps that have been taken to improve its investigatory processes, given the significance of the issues that were raised, I believe it is necessary to ask the Trust to confirm these in writing and provide further evidence that it has addressed the issues that arose in the investigation of this case. In particular, the need to cooperate with police investigations was noted to be a learning point for one witness but wider learning for the Trust as a whole was not adduced in evidence .
” Source location George Watson · Prevention of Future Deaths report
Open source report
20 Jul 2015 Craig Roberts and 2 others · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2
Lack of a clear pathway for communicating safety lessons View source Failure to implement lessons from previous heat-illness and tracking events View source
This report raised 17 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. 2
Ministry of Defence
Reinforce the formal lessons-learning process through the Training Governance and Assurance Policy review and biannual training reviews.
View source
Ministry of Defence
Conduct a Service Inquiry into the incident and wider endurance-training safety lessons across Defence.
View source
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AI-generated summary
Craig Roberts and 2 others · 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
Craig Roberts, James Dunsby and Edward Maher were reserve soldiers taking part in a specialist-unit selection test march in the Brecon Beacons in July 2013. The report identifies concerns about heat-illness guidance, training and risk assessment, communication of weather information, medical planning, emergency response, tracking of slow or static candidates, and the failure to implement lessons from previous incidents.
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 Lack of a clear pathway for communicating safety lessons
Wider context from the report “(10) A previous fatality, Soldier G see LAIT report October 2012, had identified that treatment for casualties should be within the “golden hour”. In addition following Private Poole’s death in 2009 it was identified that the tracker was not fit for purpose and standard operating procedures were issues dated January 2011. None of these recommendations were implemented by those involved in this exercise. I am concerned that lessons had not been learnt from these previous events. There appears to be no clear pathway for communicating this sort of information .
” Source location Craig Roberts and 2 others · 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 implement lessons from previous heat-illness and tracking events
Wider context from the report “(10) A previous fatality, Soldier G see LAIT report October 2012, had identified that treatment for casualties should be within the “golden hour”. In addition following Private Poole’s death in 2009 it was identified that the tracker was not fit for purpose and standard operating procedures were issues dated January 2011. None of these recommendations were implemented by those involved in this exercise . I am concerned that lessons had not been learnt from these previous events . There appears to be no clear pathway for communicating this sort of information.
” Source location Craig Roberts and 2 others · Prevention of Future Deaths report
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 Reinforce the formal lessons-learning process through the Training Governance and Assurance Policy review and biannual training reviews.
Verbatim wording from the response “There is a formal process in place for the capturing of lessons learnt/identified (Land Forces Standing Order (LFSO) 1118 – Learning Lessons in the Land Environment). Lessons are managed through the Defence Lessons Implementation and Management System (DLIMS) process which provides for a comprehensive way in which to consider that appropriate lessons are learnt, and that all appropriate steps are taken to prevent or minimise a recurrence. There is a clear and well established process, which is now being reinforced through the Training and Governance Policy review referred to under” Source location 2015-0228-Response-by-MOD
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a Service Inquiry into the incident and wider endurance-training safety lessons across Defence.
Verbatim wording from the response “We continue to work with the Health and Safety Executive to take forward their recommendations and seek their advice on implementing improved processes. I have directed that two further inquiries be conducted by the Ministry of Defence. Firstly, a Service Inquiry will look at the events of 13 July 2013 to try and ensure that all safety-related lessons, including those identified in your Regulation 28 report, are learnt for endurance training across the whole of Defence. This will be conducted by a Service Inquiry Panel, convened by the Director General Defence Safety Authority, which will provide an independent, thorough and objective review outside of the chain of command. In order to ensure all relevant issues are captured and considered by the Service Inquiry, I have also written to the Director of Specialist Military Units,” Source location 2015-0228-Response-by-MOD
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A formal, established process already captures and manages lessons learned, with the Training Governance and Assurance Policy review reinforcing it.
Verbatim wording from the response “There is a formal process in place for the capturing of lessons learnt/identified (Land Forces Standing Order (LFSO) 1118 – Learning Lessons in the Land Environment). Lessons are managed through the Defence Lessons Implementation and Management System (DLIMS) process which provides for a comprehensive way in which to consider that appropriate lessons are learnt, and that all appropriate steps are taken to prevent or minimise a recurrence. There is a clear and well established process, which is now being reinforced through the Training and Governance Policy review referred to under” Source location 2015-0228-Response-by-MOD
Open published response
29 Apr 2015 Doreen Wood · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Failure to ensure learning from INR dosing events reaches all GPs at the practice View source
This report raised 2 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
Doreen Wood · 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
Doreen Wood, who had atrial fibrillation and was taking Warfarin, died on 25 September 2014 from an intracerebral haemorrhage after repeated raised INR results. The report raised concerns that her INR was not checked soon enough and that the surgery’s monitoring system relied on healthcare assistants to volunteer relevant clinical information without routinely using standardised questionnaires.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure learning from INR dosing events reaches all GPs at the practice
Wider context from the report “(1) I invite Newgate Street surgery to review their system of INR monitoring, in discussion with Nottinghamshire Healthcare NHS Foundation Trust.
(2) Specifically, I invite the surgery to consider the use of standardised questionnaires, and not rely on healthcare assistants to volunteer – or indeed be aware of – relevant clinical information to pass on to the GP when dosing decisions are made.
(3) There has been no internal investigation of these matters within the practice, other than a discussion between two of the GPs who treated Mrs Wood. We heard that there are at least six other GPs at the practice who deal with decisions like this on a regular basis. I invite the practice to carry out its own internal investigation, to ensure that the learning from these events includes all GPs at the practice .
” Source location Doreen Wood · Prevention of Future Deaths report
Open source report
28 Apr 2015 Colour Sergeant Martyn HORTON and 3 others · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 1
Failure to capture recurring component bolt retightening as an issue warranting investigation View source
This report raised 5 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
Ministry of Defence
Review component-failure-awareness training and direct inclusion of lessons on fault reporting and experienced diagnosis.
View source
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AI-generated summary
Colour Sergeant Martyn HORTON and 3 others · 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
On 23 June 2010, four service personnel died by drowning after their Ridgeback vehicle collided with a parked Afghan National Police vehicle, left the road and overturned in a canal in Afghanistan. The report raised concerns about the Ridgeback and related vehicle fleet, including suspension fitness, driver and gunner height restrictions, lighting effectiveness, tyre-pressure equipment, maintenance documentation, emergency lighting and recognition of recurring component failures.
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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 capture recurring component bolt retightening as an issue warranting investigation
Wider context from the report “(VII) Component failure awareness. It was clear in 2010 that failures associated with the front suspension and spring hanger assembly in the Cougar fleet were starting to develop and following an incident involving a Ridgeback vehicle in Bovingdon in 2012, Qinetiq were instructed to analyse these failures. During the course of the evidence I heard from those that were maintaining these vehicles back in 2010 that the bolts on the front spring hanger assembly were in need of regular tightening and the vehicle was subject to 21 day inspection checks. The joint opinion of ████████ and members of the team at 1710 Naval Squadron was that it should not be necessary to repeatedly have to tighten the bolts relative to a component such as the spring hanger assembly. The need for the retightening of bolts was in their view indicative of a component issue and I would ask that you review from a learning point as regards raising the awareness of Craftsmen and Technicians and not just in relation to Ridgeback or Mastiff but in relation to any component across the services, that if an issue arises requiring regular or unusually frequent tightening of component bolts that matter ought to be highlighted as a concern warranting proportionate investigation relative to other similar pieces of equipment experiencing the same issue , such as was the case here with the Cougar fleet of vehicles. The retightening of bolts on a regular basis was something that was not captured as an issue in itself.
” Source location Colour Sergeant Martyn HORTON and 3 others · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review component-failure-awareness training and direct inclusion of lessons on fault reporting and experienced diagnosis.
Verbatim wording from the response “A review of current training in respect of component failure awareness has been completed. This has resulted in direction to include additional lessons to reinforce the reasons and timeframe for raising fault reports, and the importance of experienced tradespersons diagnosing and reporting equipment failure to effective equipment support.” Source location 2015-0164-Response-by-Ministry-of-Defence
Open published response
Concerns raised 1
Failure to rectify previously identified patient handover delays View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Betsi Cadwaladr University LHB Welsh Ambulance Services NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Use the Ysbyty Gwynedd handover protocol across the Health Board as an interim consistent approach pending formal policy approval.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Consult on and ratify revised ambulance handover protocols before formal implementation across the Health Board and Trust.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Implement the revised ambulance handover safety audit across the Health Board and report its results monthly.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Establish holding areas in each Emergency Department when required to enable safe, timely patient offloading.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Investigate serious incidents involving both organisations jointly and share the resulting learning.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Enhance senior clinical, nursing and operational leadership to support Emergency Departments and patient flow.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Consult on and ratify a North Wales escalation protocol before implementing it across the area.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Issue Medical Director advice supporting joint assessment of ambulance patients at Emergency Department front doors and safe transfer of suitable patients.
View source
Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS Trust
Operate cross-organisational escalation arrangements and conference calls to agree joint action plans for ongoing handover delays.
View source See 6 more actions
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AI-generated summary
Clive Harold 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
Clive Harold Turner was taken to hospital after delays in the response to a call for medical assistance and was discharged after being incorrectly diagnosed as constipated. He was later found deceased at home from a gastrointestinal haemorrhage due to ischaemic bowel resulting from atherosclerosis. Concerns included uncertainty about pain relief provided by the ambulance service, lack of awareness of overnight discharge policies, and the absence of senior clinicians available for a second opinion.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to rectify previously identified patient handover delays
Wider context from the report “3. It is of considerable concern to me that item 2 above is a direct repeat of a concern which I raised in a previous Regulation 28 report following the death of Mr Frederick Pring in March 2013, twelve months before that of Mr Turner, the joint response of WAST and BCUHB being received exactly one week before Mr Turner's death.
” Source location Clive Harold Turner · Prevention of Future Deaths report
Open source 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 Use the Ysbyty Gwynedd handover protocol across the Health Board as an interim consistent approach pending formal policy approval.
Verbatim wording from the response “BCUHB has developed a protocol for their area to ensure a consistent approach to ambulance handover across North Wales. The Medical Director has mandated the protocol that is currently used at Ysbyty Gwynedd Hospital to be used across the Health Board for use in the interim period until a new Handover Policy for BCUHB can be formally agreed. The revised protocols are currently out for consultation and will require ratification by both BCUHB and the Trust prior to formal implementation.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
Open published response
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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 Consult on and ratify revised ambulance handover protocols before formal implementation across the Health Board and Trust.
Verbatim wording from the response “BCUHB has developed a protocol for their area to ensure a consistent approach to ambulance handover across North Wales. The Medical Director has mandated the protocol that is currently used at Ysbyty Gwynedd Hospital to be used across the Health Board for use in the interim period until a new Handover Policy for BCUHB can be formally agreed. The revised protocols are currently out for consultation and will require ratification by both BCUHB and the Trust prior to formal implementation.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
Open published response
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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 revised ambulance handover safety audit across the Health Board and report its results monthly.
Verbatim wording from the response “The audit of ambulance handover to provide assurance in relation to patient safety during this period of care has been revised by the BCUHB Associate Medical Director for Unscheduled Care. The new process has been piloted at one of the Emergency Departments in North Wales and following some amendment will be implemented across BCUHB and reported monthly. This has already commenced in Ysbyty Glan Clwyd.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
Open published response
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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 Establish holding areas in each Emergency Department when required to enable safe, timely patient offloading.
Verbatim wording from the response “Holding areas are being established in each Emergency Department when required to enable patients to be offloaded in a safe and timely manner. Serious incidents where there are joint issues for BCUHB and the Trust are now investigated jointly and learning outcomes shared. Senior Clinical, Nurse and Operational Management Leadership have been enhanced by the Health Board to ensure robust support for the Emergency Departments and patient flow.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
Open published response
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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 Investigate serious incidents involving both organisations jointly and share the resulting learning.
Verbatim wording from the response “Holding areas are being established in each Emergency Department when required to enable patients to be offloaded in a safe and timely manner. Serious incidents where there are joint issues for BCUHB and the Trust are now investigated jointly and learning outcomes shared. Senior Clinical, Nurse and Operational Management Leadership have been enhanced by the Health Board to ensure robust support for the Emergency Departments and patient flow.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
Open published response
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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 Enhance senior clinical, nursing and operational leadership to support Emergency Departments and patient flow.
Verbatim wording from the response “Holding areas are being established in each Emergency Department when required to enable patients to be offloaded in a safe and timely manner. Serious incidents where there are joint issues for BCUHB and the Trust are now investigated jointly and learning outcomes shared. Senior Clinical, Nurse and Operational Management Leadership have been enhanced by the Health Board to ensure robust support for the Emergency Departments and patient flow.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
Open published response
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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 Consult on and ratify a North Wales escalation protocol before implementing it across the area.
Verbatim wording from the response “BCUHB has developed an escalation protocol for their area to ensure a consistent approach across North Wales. The protocol is currently out for consultation and will require ratification by the North Wales Unscheduled Care Programme Board prior to implementation. This has included advice issued by the Medical Director to support and encourage NHS Managers and Clinicians to work closely with the Trust staff at the Emergency Departments (ED) ‘front doors’ to jointly assess patients held in ambulances and identify patients that could either safely be transferred to the waiting room or be brought into the department without delay.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
Open published response
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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 Issue Medical Director advice supporting joint assessment of ambulance patients at Emergency Department front doors and safe transfer of suitable patients.
Verbatim wording from the response “BCUHB has developed an escalation protocol for their area to ensure a consistent approach across North Wales. The protocol is currently out for consultation and will require ratification by the North Wales Unscheduled Care Programme Board prior to implementation. This has included advice issued by the Medical Director to support and encourage NHS Managers and Clinicians to work closely with the Trust staff at the Emergency Departments (ED) ‘front doors’ to jointly assess patients held in ambulances and identify patients that could either safely be transferred to the waiting room or be brought into the department without delay.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
Open published response
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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 Operate cross-organisational escalation arrangements and conference calls to agree joint action plans for ongoing handover delays.
Verbatim wording from the response “There is engagement at all levels between the Trust and BCUHB, with conference calls arranged to agree joint action plans to address ongoing delays. Duty Control Managers from the Trust will initially contact the Hospital Clinical Site Managers if ambulances are delayed. The escalation process will continue with the Trusts Locality Managers contacting the Senior Site Operational Managers in BCUHB and then the Trusts Head of Service engaging with the Chief Operating Officer within BCUHB out of hours as there is an ‘On Call’ system Bronze to Bronze, Silver to Silver and Gold to Gold engagement between both organisations to ensure that a seamless escalation process exists.” Source location 2014-0404-Response-by-Welsh-Ambulance-Service
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.