Recurring concern

Failure to reliably recognise and respond to acute clinical deterioration

First to latest report 24 Sep 2013 — 24 Jun 2026

Reports that mention this concern
103
Times this concern has been raised
127
Stated actions linked to this concern
169

What this concern includes

Includes failures to recognise, monitor, escalate, obtain clinical review for or respond to acute physical deterioration when the deterioration hazard itself is directly asserted.

What is not included
  • Excludes generic communication, staffing, training or senior-oversight failures not directly tied to an identified deterioration episode or control.
  • Excludes deterioration in mental health, and condition-specific systems that do not establish a wider acute-deterioration failure.

Reports and published responses 103 reports

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

  1. Coventry

    AI-generated summary

    Vanessa Ferkova and Sylvia Daniel · 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

    Vanessa Ferkova, aged 2, died after presenting to a walk-in centre with fever and vomiting, developing a rash, and later suffering cardiac arrest; the report states she died from meningococcus septicaemia. Sylvia Daniel, aged 73, presented with symptoms including neck pain, was diagnosed with an ear infection, and was found deceased the following morning; the report states she died from acute meningitis. Concerns included delays and deficiencies in initial assessment and registration, failure to transcribe or retain information provided by families, and an unsafe non-clinical triage and flagging process.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to act on deterioration or requests for earlier prompt review raised through the flagging process

    Wider context from the report

    “4. My final specific concern relates to the process whereby patients/families are asked to let the reception team know if the patient is deteriorating, or if they are concerned that earlier prompt review is required. I heard evidence that such concerns were raised but no action was taken. This seemingly runs counter to Virgin Care’s own ‘flagging’ system. ”

    Source location

    Vanessa Ferkova and Sylvia Daniel · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. West Sussex

    AI-generated summary

    MARGARET STEMP · 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

    Margaret Stemp, aged 91, was found deceased on 28 December 2017 after she and her sister had fallen and remained on the floor for over seven hours before police assistance. The inquest concluded that she died from natural causes following a long lie on the floor where there had been missed opportunities for medical intervention. Concerns included insufficient ambulance resources, reliance on police for welfare support, failure to recognise worsening circumstances, and no clinical oversight of the decision to stand down the ambulance response.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of call takers to recognise worsening condition

    Wider context from the report

    “(3) That the call takers did not seem to appreciate the worsening condition of these two ladies during the time they were seeking assistance. ”

    Source location

    MARGARET STEMP · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide enhanced training to existing Support Call Takers on recognising deterioration and responding appropriately.

    Verbatim wording from the response

    “As a result of this incident, all Support Call Takers have received, and new SCT’s will receive on induction, enhanced training with an emphasis on how to recognise worsening of a patient’s condition and what action to take on recognising that fact. We have introduced a new Patient Welfare Procedure, which involves SCT’s working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queue/waiting calls and help manage them more efficiently from a clinical perspective. In addition, a system of audit of SCTs’ work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring.”

    Source location

    2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 10 July 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide enhanced deterioration-recognition training to new Support Call Takers during induction.

    Verbatim wording from the response

    “As a result of this incident, all Support Call Takers have received, and new SCT’s will receive on induction, enhanced training with an emphasis on how to recognise worsening of a patient’s condition and what action to take on recognising that fact. We have introduced a new Patient Welfare Procedure, which involves SCT’s working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queue/waiting calls and help manage them more efficiently from a clinical perspective. In addition, a system of audit of SCTs’ work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring.”

    Source location

    2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 10 July 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement a Patient Welfare Procedure requiring Support Call Takers to work with Clinical Navigators to manage waiting calls clinically.

    Verbatim wording from the response

    “As a result of this incident, all Support Call Takers have received, and new SCT’s will receive on induction, enhanced training with an emphasis on how to recognise worsening of a patient’s condition and what action to take on recognising that fact. We have introduced a new Patient Welfare Procedure, which involves SCT’s working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queue/waiting calls and help manage them more efficiently from a clinical perspective. In addition, a system of audit of SCTs’ work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring.”

    Source location

    2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 10 July 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce an audit system for Support Call Takers’ work, including audit criteria and scoring.

    Verbatim wording from the response

    “As a result of this incident, all Support Call Takers have received, and new SCT’s will receive on induction, enhanced training with an emphasis on how to recognise worsening of a patient’s condition and what action to take on recognising that fact. We have introduced a new Patient Welfare Procedure, which involves SCT’s working more closely with our new Clinical Navigators, who are clinicians who oversee the clinical queue/waiting calls and help manage them more efficiently from a clinical perspective. In addition, a system of audit of SCTs’ work is to be introduced, to bring them in line with the quality assurance system in place for our 999 call takers. This project is at the planning stage, as we will need additional resources to carry out the audits and we are defining the criteria for the audit tool which will set out the audit elements and scoring.”

    Source location

    2018-0198-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 10 July 2018

    Open published response

  3. Manchester North

    AI-generated summary

    Miss Lea Louise Hunsley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to identify, recognise and act upon deteriorating patients

    Wider context from the report

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

    Source location

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

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to escalate deteriorating patients for medical review

    Wider context from the report

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

    Source location

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

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide clinical-observation training to staff, including basic resuscitation training.

    Verbatim wording from the response

    “• Staff have undertaken clinical observation training.”

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish accredited nurse-manager training capacity to deliver clinical-observation training across staff shifts.

    Verbatim wording from the response

    “• Nurse managers/seniors have received accredited train the trainer presentation skills course and have had training to deliver accredited clinical observations training ourselves. This will ensure it is delivered to staff at times that suit our needs, enabling more staff to access training.”

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement an updated When to Seek Medical Advice policy, requiring staff acknowledgement and signatures and addressing family concerns.

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

  4. Nottinghamshire

    AI-generated summary

    Joan Osborne · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to recognise and seek help for a deteriorating condition

    Wider context from the report

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

    Source location

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

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver Nutrition and Diabetes Management Training to nursing home staff.

    Verbatim wording from the response

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

    Source location

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

    Open published response

  5. Inner North London

    AI-generated summary

    Georgia Polydorou · 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

    Georgia Polydorou was an in-patient being treated for congestive cardiac failure when she fell while going to the toilet on 10 July 2017. She later became unresponsive and was found to have a large acute subdural haematoma; after surgery and a prolonged period on a ventilator, she died on 18 September 2017. Concerns included the decision not to perform a CT scan within eight hours of the fall despite concurrent use of aspirin, clopidogrel and enoxaparin, the delayed presentation of head-injury signs in elderly patients, and communication difficulties relating to her limited English and the significance of headache after the fall.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to communicate the significance of post-fall deterioration signs to patients’ interpreters or carers

    Wider context from the report

    “(3) Mrs Polydorou’s first language was Greek. Witnesses described her ability to converse in English as “basic”. Whilst in A&E, her son acted as an interpreter in order to obtain a reliable history. Following the fall, it was decided that Mrs Polydorou would have a CT scan if she showed signs of deterioration such as headache, bleeding, dizziness or vomiting. Mrs Polydorou’s son, ████████ was told that his mother had fallen but was not told of the significance that may indicate that her condition was deteriorating. During a visit on 10 July, Mrs Polydorou told her son that she had a headache but he did not realise the potential significance of this. Mrs Polydorou did not report her headache to medical staff. ”

    Source location

    Georgia Polydorou · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Nottinghamshire

    AI-generated summary

    Elaine Bradbrook · 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

    Elaine Bradbrook suffered a severe ischaemic stroke, deteriorated into a deep coma, underwent a craniectomy, and died at Queen’s Medical Centre on 27 April 2017. Concerns included failures to escalate and monitor her deterioration, reassess her condition before transfer, and reduce risks during transfer, including transfer with an unprotected airway and without clinical escort. The report also raised concerns about the trust’s failure to investigate the circumstances, fulfil its duty of candour, and support or properly represent witnesses during the inquest.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide clinical or nursing review after deterioration in consciousness

    Wider context from the report

    “b. There was a failure to record a single GCS after 14.00, when her level of consciousness dropped. I found no evidence of any clinical or nursing review after this time. ”

    Source location

    Elaine Bradbrook · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to escalate and act on a deteriorating patient condition

    Wider context from the report

    “a. There was a failure to escalate and act on Elaine’s deteriorating condition from at least 14.00 on 22 April 2017, when her NEWS was 6, and her GCS is also likely to have dropped. ”

    Source location

    Elaine Bradbrook · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Commence a serious incident investigation to review the care provided.

    Verbatim wording from the response

    “I agree that there are clear learning points from this case and I have asked the Risk Team to commence an SI investigation to review the care and submit an action plan, as necessary. I will of course share this with you and the family once complete.”

    Source location

    2018-0044-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
    Page 1 · response
    Published 7 June 2018

    Open published response

  7. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Reginald George KEY · 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

    Reginald George KEY underwent surgery and was discharged from hospital on 1 December 2016. He was reportedly very unwell when delivered home after a delay in patient transport and was readmitted on 4 December with sepsis. He underwent further procedures and died on 10 December 2016; concerns were raised about his discharge condition, the delay in transport, and whether his deterioration could have been identified or whether paramedics could have returned him to hospital.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to identify deterioration during patient transport

    Wider context from the report

    “• The deceased had undergone surgery and was apparently discharged from the Royal Stoke University Hospital at 6pm on 1st December 2016. He was collected by patient transport. Clinicians tell me he was well on discharge. He was apparently deliver home at 10pm some 4 hours later when he was described as being very unwell with paramedics commenting that he should not have been discharged and that they had to carry him into the house. Family noted there were other patients in the transport vehicle awaiting return home. • Family and clinicians raised concerns about the length of time it had apparently taken to deliver him home and whether or not his deteriorating condition was or could have been spotted and whether there was an option for paramedics to return him to the hospital. He was returned to hospital very unwell on the 4th December 2016. ”

    Source location

    Reginald George KEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Instruct the provider to produce an action plan addressing the identified patient transport safety measures.

    Verbatim wording from the response

    “Assurances Undertaken to Prevent Future Deaths To address the Coroner’s concerns we have instructed the provider to act upon the findings and include in their action plan the following:”

    Source location

    2018-0025-Response-by-Cannock-Chase-CCG-NHS-Trust
    Page 2 · response
    Published 20 March 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the provider’s action plan at the April 2018 contract and quality meeting, request measurable outcomes, and monitor progress until actions are concluded.

    Verbatim wording from the response

    “We have instructed the provider to produce an action plan to address these matters. This plan will be reviewed in detail at the next provider contract and quality meeting in April 2018 by my commissioning and quality teams and will be monitored at this meeting until all actions are concluded and agreed between the provider organisation and the CCGs.”

    Source location

    2018-0025-Response-by-Cannock-Chase-CCG-NHS-Trust
    Page 3 · response
    Published 20 March 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Transport records contradict the reported four-hour journey and record no observed deterioration or route deviation.

    Verbatim wording from the response

    “17:16 and show that he had been collected by the crew at 17:50. The PTS crew had left the hospital at 18:09 and Mr Key arrived back to his home address in Hednesford at 19:15. We have confirmed that the crew consisted of two patient transport assistants and that these were not paramedics. The PTS service have no record of any concerns being raised by their crew under their deteriorating patient policy and no indication that the crew deviated from the plan as indicated by their transport monitoring system.”

    Source location

    2018-0025-Response-by-Cannock-Chase-CCG-NHS-Trust
    Page 2 · response
    Published 20 March 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Hospital transfers requiring escalation are handled by the 999 ambulance service, not patient transport staff.

    Verbatim wording from the response

    “We have discussed the level of skill and escalation procedure with the PTS provider. They have reported all staff are aware of the deteriorating patient policy and they expect staff to enact this when they have any patient concerns. Staff are instructed at times of a medical emergency and/or concerns around the patients’ health, that they are to stop the vehicle and inform the ambulance service of the nature of the emergency and await the service to respond. It is important to highlight that they are not allowed to transport a patient to hospital and are required to seek professional help via the 999 service.”

    Source location

    2018-0025-Response-by-Cannock-Chase-CCG-NHS-Trust
    Page 2 · response
    Published 20 March 2018

    Open published response

  8. Staffordshire South

    AI-generated summary

    John Keith Edwards · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to recognise residents’ deteriorating condition

    Wider context from the report

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

    Source location

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

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

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

    Wider context from the report

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

    Source location

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

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

  9. Manchester North

    AI-generated summary

    Mrs Lindsey Parker · 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

    Mrs Lindsey Parker had metastatic lung cancer and subsequently developed toxic epidermal necrolysis while receiving medical treatment. Her condition deteriorated on 8 July 2017, with concerns about delayed medical review, inadequate recognition and escalation of deterioration, gaps in observations and fluid-balance recording, lack of continuity in medical care, and the qualifications of out-of-hours coordinators. She died at Salford Royal Hospital on 9 July 2017.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to act on or escalate patient deterioration

    Wider context from the report

    “3. Failure to adequately recognise the deteriorating patient and to act and/or escalate matters accordingly. ”

    Source location

    Mrs Lindsey Parker · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Maintain electronic NEWS scoring linked to bedside vital-sign recording and observation-frequency escalation.

    Verbatim wording from the response

    “Compliance with adult observation physiological monitoring policy”

    Source location

    2017-0378-Response-by-Northern-Care-Alliance-NHS-Group
    Page 3 · response
    Published 12 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Update ward safety-huddle content to identify patients requiring hourly urine-output monitoring and address responses to deteriorating NEWS scores.

    Verbatim wording from the response

    “Mrs Parker was having her fluid balance monitored (fluid intake measured against urine output to ensure hydration). Patients with the condition TEN can lose high amounts of fluid through their skin and it is essential to monitor the urine output as this will indicate if a patient is becoming dehydrated. Mrs Parker was having her urine output measured hourly and the overall daily balance would have been calculated at midnight. On two occasions the urine output was not charted hourly. This is below the expected standard and the individuals have reflected upon their practice and learned from this event. The Ward Matron has also discussed the learning with the ward team and made changes to the content of the daily ward safety huddle to acknowledge which patients are requiring hourly urine output monitoring.”

    Source location

    2017-0378-Response-by-Northern-Care-Alliance-NHS-Group
    Page 4 · response
    Published 12 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct weekly audits of elevated-NEWS escalation to verify compliance with the adult observation policy timeframe.

    Verbatim wording from the response

    “On review, although Mrs Parker’s clinical observations were escalated initially for review by the FY1 and Dermatology Registrar, the nursing staff should have persisted to escalate them when Mrs Parker began to deteriorate. Again, this has been discussed with the staff involved for their individual learning and concerns regarding a response to deteriorating NEWS has been added to the ward safety huddle.”

    Source location

    2017-0378-Response-by-Northern-Care-Alliance-NHS-Group
    Page 4 · response
    Published 12 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Discuss deterioration-response learning with staff involved and support individual practice learning.

    Verbatim wording from the response

    “On review, although Mrs Parker’s clinical observations were escalated initially for review by the FY1 and Dermatology Registrar, the nursing staff should have persisted to escalate them when Mrs Parker began to deteriorate. Again, this has been discussed with the staff involved for their individual learning and concerns regarding a response to deteriorating NEWS has been added to the ward safety huddle.”

    Source location

    2017-0378-Response-by-Northern-Care-Alliance-NHS-Group
    Page 4 · response
    Published 12 February 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Hospital at Night model, senior nurse triage and multidisciplinary onsite team provide sufficient out-of-hours prioritisation and care.

    Verbatim wording from the response

    “Salford Royal NHS Foundation Trust adopts the ‘Hospital at Night’ model. This is a clinically driven and patient focused model, which uses both a multi-professional and multispecialty approach to delivering care at night and out of hours. The programme enhances patient safety and outcomes, and supports medical training and service delivery. The Hospital at Night concept proposes that the way to achieve safe clinical care is to have one or more multi-professional teams who have the full range of skills and competences to meet the immediate needs of patients.”

    Source location

    2017-0378-Response-by-Northern-Care-Alliance-NHS-Group
    Page 4 · response
    Published 12 February 2018

    Open published response

  10. West Sussex

    AI-generated summary

    Dennis Allen Teesdale · 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

    Dennis Allen Teesdale underwent surgery including insertion of a PEG tube on 17 October 2016 and subsequently developed severe abdominal pain, multi-organ failure and septic shock. He was found to have peritonitis caused by leakage of bowel contents from the PEG tube passing through the bowel, and died on 20 October 2016. Concerns included the insertion and post-operative management of the PEG, delayed recognition and treatment of deterioration, delayed transfer, and limitations in specialist, diagnostic and laboratory services at Queen Victoria Hospital.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to recognise severe clinical deterioration on consultant ward rounds

    Wider context from the report

    “10. There was no recognition of how unwell Mr Teesdale was on the consultant surgical ward round at or around 0900 on the 19th October 2016, despite considerable evidence present at the time that Mr Teesdale had developed multi-organ failure. ”

    Source location

    Dennis Allen Teesdale · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Define critical-care leadership and accountability under the consultant in charge, with consultant-led handover for junior night staff.

    Verbatim wording from the response

    “Leadership of the critical care unit has been better defined with an improved system of handover, and the on-site consultant presence has been extended recently, with consultant led handover for junior night staff.”

    Source location

    Dennis-Teesdale-Response-1
    Page 5 · response
    Published 28 July 2017

    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

    Use unified multidisciplinary critical-care documentation and audit its implementation within the enhanced recovery programme.

    Verbatim wording from the response

    “The Coroner drew attention to inconsistencies between the ‘snap shot’ medical reviews and the more frequent reviews of the nursing staff. Since Mr Teesdale’s death, we have developed unified multidisciplinary documentation as part of the enhanced recovery programme, and are auditing its use. Multidisciplinary documentation will be further developed as we progress with electronic document management.”

    Source location

    Dennis-Teesdale-Response-1
    Page 6 · response
    Published 28 July 2017

    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

    Monitor the trust’s prospective PEG audit through routine engagement, including adherence to policy and timely escalation of deterioration.

    Verbatim wording from the response

    “Although the trust carried out two PEG insertions since the request, only one of these took place after they introduced the new PEG Pathway on 5 June 2017. The trust confirmed the PEG Pathway was followed for this patient. We will continue to monitor the trust’s prospective PEG audit, which will capture this information, as part of our ongoing engagement with the trust.”

    Source location

    2017-0202-Response-by-Care-Quality-Commission
    Page 5 · response
    Published 28 July 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    NHS Improvement, NHS England, and the Care Quality Commission, working with the Trust and commissioners, were responsible for ensuring appropriate action.

    Verbatim wording from the response

    “Finally, I am satisfied that the regulators are alert to the risks you have highlighted, and it is for NHS Improvement, NHS England and the Care Quality Commission, working with the Trust and its commissioners, to ensure sufficient and appropriate action is taken to address the concerns raised. My officials have asked to be kept informed of developments.”

    Source location

    2017-0202-Response-by-Department-of-Health
    Page 3 · response
    Published 28 July 2017

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026