Recurring concern

Failure to reliably recognise and respond to acute clinical deterioration

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First reported 24 Sep 2013•Latest report 24 Jun 2026

Definition

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.

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: 103
Individual concerns: 127
Date range: 2013–2026
Stated actions: 169

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care14

NHS England10

Care Quality Commission6

University Hospitals Sussex NHS Foundation Trust6

National Institute for Health and Care Excellence4

Nottinghamshire Healthcare NHS Foundation Trust4

Recipient name withheld3

Royal Sussex County Hospital3

Barts Health NHS Trust2

College of Policing2

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust2

Lewisham and Greenwich NHS Trust2

Manchester University NHS Foundation Trust2

Medway NHS Foundation Trust2

Metropolitan Police Service2

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

16 Feb2021
West Yorkshire Eastern
Concerns raised2
1. Failure to escalate deteriorating postoperative patients to senior clinicians
2. Lack of clear escalation procedures and training for deteriorating postoperative patients
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Require the consultant anaesthetist to define postoperative care and NEWS thresholds for escalation to critical care outreach.
  Stated by Leeds Teaching Hospitals NHS TrustStated planned
2. Action
  Implement defined daytime and out-of-hours escalation using consultant contacts, NEWS2 and applicable deteriorating-patient and transfer policies.
  Stated by Leeds Teaching Hospitals NHS TrustStated planned
3. Action
  Develop a dedicated policy for deteriorating patients cared for at peripheral hospital sites.
  Stated by Leeds Teaching Hospitals NHS TrustStated in progress
1. Action
  Establish a dedicated on-call consultant rota for Chapel Allerton Hospital.
  Stated by Leeds Teaching Hospitals NHS TrustStated in progress
2. Action
  Extend on-site anaesthetic and recovery-unit cover until 21:00.
  Stated by Leeds Teaching Hospitals NHS TrustStated planned
3. Action
  Provide rolling staff education and mandatory escalation-pathway and resuscitation training, recording junior doctors’ training on Electronic Staff Records.
  Stated by Leeds Teaching Hospitals NHS TrustStated planned
AI-generated summary

Mrs Ruby Baggaley · 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 Ruby Baggaley, aged 90, sustained a right distal femur fracture in a fall and died in hospital on the night of 24 January 2020 after complex surgery. Her blood pressure remained abnormally low after surgery, but escalation to senior clinicians was delayed until she was critically ill. Concerns included inadequate monitoring and failure to escalate her deteriorating condition, as well as uncertainty about whether clear escalation instructions and additional staff training had been implemented.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to escalate deteriorating postoperative patients to senior clinicians
Wider context from the report
“In the period from 17:00 hours onwards her care was exclusively in the hands of a relatively junior doctor (CT2) and the nursing staff. No attempt was made to inform the surgeons or anaesthetist of the deterioration in her condition. 3) Between 16:00 hours and 20:45 hours Mrs Baggaley’s NEWS Score was 5 and remained at this level. No attempt was made to escalate her care to more senior clinicians. It is not clear whether junior doctors and nursing staff now have clear instructions on when to escalate care in such circumstances, nor to whom. 4) By the time the surgeon was informed of the situation and travelled into the hospital around 22:00 hrs Mrs Baggaley’s condition had become critical. It is not clear whether earlier intervention by senior clinicians would have avoided Mrs Baggaley suffering a cardiac arrest consequent upon her low blood pressure (as the Inquest was informed was the case). It is quite clear, however, that she was deprived of the opportunity to have a review by a senior clinician. 5) I am concerned that in the absence of precise information as to what, if any changes in escalation procedures have been implemented, or additional training provided to the staff involved, the potential for a comparable situation to occur again, remains. ”
Source location
Mrs Ruby Baggaley · Prevention of Future Deaths report
Page 1 · 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
Lack of clear escalation procedures and training for deteriorating postoperative patients
Wider context from the report
“In the period from 17:00 hours onwards her care was exclusively in the hands of a relatively junior doctor (CT2) and the nursing staff. No attempt was made to inform the surgeons or anaesthetist of the deterioration in her condition. 3) Between 16:00 hours and 20:45 hours Mrs Baggaley’s NEWS Score was 5 and remained at this level. No attempt was made to escalate her care to more senior clinicians. It is not clear whether junior doctors and nursing staff now have clear instructions on when to escalate care in such circumstances, nor to whom. 4) By the time the surgeon was informed of the situation and travelled into the hospital around 22:00 hrs Mrs Baggaley’s condition had become critical. It is not clear whether earlier intervention by senior clinicians would have avoided Mrs Baggaley suffering a cardiac arrest consequent upon her low blood pressure (as the Inquest was informed was the case). It is quite clear, however, that she was deprived of the opportunity to have a review by a senior clinician. 5) I am concerned that in the absence of precise information as to what, if any changes in escalation procedures have been implemented, or additional training provided to the staff involved, the potential for a comparable situation to occur again, remains. ”
Source location
Mrs Ruby Baggaley · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Require the consultant anaesthetist to define postoperative care and NEWS thresholds for escalation to critical care outreach.

Verbatim wording from the response
“On the day of surgery, the consultant anaesthetist will have the responsibility to clearly define the patient’s post-operative care, including NEWS scores that will require escalation to critical care outreach team for support out of hours.”

Source location
2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
Page 3 · response
Published 22 February 2021
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 defined daytime and out-of-hours escalation using consultant contacts, NEWS2 and applicable deteriorating-patient and transfer policies.

Verbatim wording from the response
“During daytime working hours (08.00 -18.00) any concerns will be escalated to the consultant surgeon and anaesthetist responsible for the patient’s care. After 18.00 hours the escalation policy will be based upon clear objective assessments of the patient’s physiological status using the NEWS2 score and the Trust’s ‘Deteriorating Patient Policy’ and the ‘Transfer of Care Policy for Chapel Allerton Orthopaedic Centre’. A separate policy is being developed to specifically address the deteriorating patient being cared for in peripheral hospital sites. Plans are on-going to establish a dedicated on-call consultant rota for Chapel Allerton Hospital but in the meantime, the duty consultants at the LGI site will be available to provide advice and if necessary, review the patient.”

Source location
2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
Page 3 · response
Published 22 February 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a dedicated policy for deteriorating patients cared for at peripheral hospital sites.

Verbatim wording from the response
“During daytime working hours (08.00 -18.00) any concerns will be escalated to the consultant surgeon and anaesthetist responsible for the patient’s care. After 18.00 hours the escalation policy will be based upon clear objective assessments of the patient’s physiological status using the NEWS2 score and the Trust’s ‘Deteriorating Patient Policy’ and the ‘Transfer of Care Policy for Chapel Allerton Orthopaedic Centre’. A separate policy is being developed to specifically address the deteriorating patient being cared for in peripheral hospital sites. Plans are on-going to establish a dedicated on-call consultant rota for Chapel Allerton Hospital but in the meantime, the duty consultants at the LGI site will be available to provide advice and if necessary, review the patient.”

Source location
2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
Page 3 · response
Published 22 February 2021
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 a dedicated on-call consultant rota for Chapel Allerton Hospital.

Verbatim wording from the response
“During daytime working hours (08.00 -18.00) any concerns will be escalated to the consultant surgeon and anaesthetist responsible for the patient’s care. After 18.00 hours the escalation policy will be based upon clear objective assessments of the patient’s physiological status using the NEWS2 score and the Trust’s ‘Deteriorating Patient Policy’ and the ‘Transfer of Care Policy for Chapel Allerton Orthopaedic Centre’. A separate policy is being developed to specifically address the deteriorating patient being cared for in peripheral hospital sites. Plans are on-going to establish a dedicated on-call consultant rota for Chapel Allerton Hospital but in the meantime, the duty consultants at the LGI site will be available to provide advice and if necessary, review the patient.”

Source location
2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
Page 3 · response
Published 22 February 2021
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
Extend on-site anaesthetic and recovery-unit cover until 21:00.

Verbatim wording from the response
“In addition, contact details for the operating surgeon and anaesthetist will be available to the ward staff if required. Plans are in place to extend the anaesthetic and recovery unit cover on site until 21.00. This will facilitate the post-operative reviews and management of higher risk patients. Where possible, higher risk patients will be operated on early in the day to allow an extended period of observation before the treating surgeon and anaesthetist leave the site. In addition, every effort will be made to ensure high risk patients are not operated on at the end of the working week (i.e. on Friday).”

Source location
2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
Page 3 · response
Published 22 February 2021
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 rolling staff education and mandatory escalation-pathway and resuscitation training, recording junior doctors’ training on Electronic Staff Records.

Verbatim wording from the response
“It is recognised that a rolling programme of staff education will be required to support the implementation of these planned changes. All staff in both the operating theatres and surgical wards will have regular training on escalation pathways and resuscitation. There will be compulsory mandatory training for the junior doctors starting their post at Chapel Allerton Hospital. This will be recorded on the Electronic Staff Records.”

Source location
2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
Page 3 · response
Published 22 February 2021
Open published response
3 Feb2021
Mid Kent and Medway
Concerns raised1
1. Failure to respond appropriately to deterioration while patients remain on discharge wards
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

CHRISTOPHER SMITH · 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

Christopher Smith was admitted to hospital with peripheral vascular disease, extensive leg ulcers, epilepsy and infections, and died on 4 March 2019 after deterioration following discharge home. Principal concerns included inadequate discharge planning and capacity reassessment, failure to arrange home and district nursing support, unsafe home conditions and an unacted-on safeguarding alert, and inadequate nutritional care.

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 respond appropriately to deterioration while patients remain on discharge wards
Wider context from the report
“(3) Mr Smith remained on a discharge ward from 2nd February until his discharge on 10th February even though he suffered a deterioration in his medical condition. Mr Smith’s capacity fluctuated during his admission, he was noted by nurses to be confused and his capacity was not reassessed. ”
Source location
CHRISTOPHER SMITH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Jan2021
Nottinghamshire
Concerns raised2
1. Failure to recognise serious and deteriorating medical conditions
2. Delays in organising medical assistance for serious deterioration
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Norma Lockton · 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

Norma Lockton was a resident in a nursing home whose reduced mobility and vulnerable skin required care measures that were not followed. She developed a wound behind her left knee, which became infected and led to cellulitis and systemic sepsis; medical assistance was not sought until her condition was life threatening, and she died in hospital on 4 March 2020. The principal concerns included failures in skin care planning and implementation, repositioning, recognition of changing care needs and deteriorating health, and management review following the death.

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 serious and deteriorating medical conditions
Wider context from the report
“4. The lack of recognition of a serious and deteriorating medical condition (that of cellulitis), leading to no medical assistance being organised until the situation was life threatening. ”
Source location
Norma Lockton · 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
Delays in organising medical assistance for serious deterioration
Wider context from the report
“4. The lack of recognition of a serious and deteriorating medical condition (that of cellulitis), leading to no medical assistance being organised until the situation was life threatening. ”
Source location
Norma Lockton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
29 May2020
Inner South London
Concerns raised1
1. Failure to inform the GP of patient deterioration
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement a rescue-antibiotics policy requiring parents to contact the practice on the first treatment day.
  Stated by and the Sydenham Green Group PracticeStated completed
2. Action
  Bring together professional colleges to develop standards promoting connectivity, proactive care, and communication for children with ongoing health needs.
  Stated by Royal College of Paediatrics and Child HealthStated completed
3. Action
  Publish a position on information sharing and consistent identifiers for children to support professionals’ access to information and care coordination.
  Stated by Royal College of Paediatrics and Child HealthStated completed
AI-generated summary

Master Omarian Brooks · 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

Omarian Brooks, a severely disabled boy, deteriorated after being given antibiotics by his parents and died en route to hospital on 27 May, without having had a GP visit. Concerns included the GP apparently being unaware of his deterioration, the absence of a protocol for managing it, and the lack of a patient-specific emergency care protocol. The report states that earlier GP awareness might have led to hospital admission with a real prospect of successfully treating the infection.

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 inform the GP of patient deterioration
Wider context from the report
“1. The Record concludes that had the GP been informed of the boy’s deterioration either 4 days before the antibiotic was started or soon after, he would have been admitted to hospital with a real prospect of the infection being successfully treated. ”
Source location
Master Omarian Brooks · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement a rescue-antibiotics policy requiring parents to contact the practice on the first treatment day.

Verbatim wording from the response
“4. The GPs have implemented a policy for circumstances where ‘rescue pack’ antibiotics are prescribed to patients with complex needs on a repeat basis. This policy includes an agreement which has to be made between the GPs and the parents. This agreement”

Source location
2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
Page 1 · response
Published 10 June 2020
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
Bring together professional colleges to develop standards promoting connectivity, proactive care, and communication for children with ongoing health needs.

Verbatim wording from the response
“• In 2018, the College brought together the Royal College of General Practitioners, Royal College of Nursing, Royal College of Physicians and Royal College of Psychiatrists to develop Facing the Future: Standards for children with ongoing health needs³ to ensure connectivity between services, with a focus on improving long term care and management so that care is planned and proactive - particularly with improving communication and education for both the child and family, and communication between professionals.”

Source location
2020-0114-Response-from-the-Royal-College-of-Paediatrics-and-Child-Health_Redacted.pdf
Page 2 · response
Published 10 June 2020
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
Publish a position on information sharing and consistent identifiers for children to support professionals’ access to information and care coordination.

Verbatim wording from the response
“• The College has a published position on information sharing and maintains that having a unique, consistent identifier for children will allow professionals interacting with children to share information easily and provide better care for their needs.⁴”

Source location
2020-0114-Response-from-the-Royal-College-of-Paediatrics-and-Child-Health_Redacted.pdf
Page 2 · response
Published 10 June 2020
Open published response
27 Apr2020
Manchester South
Concerns raised1
1. Failure to escalate deterioration to a consultant
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Provide daily and twice-weekly Consultant in Care of the Elderly reviews, with escalation to senior medical staff for clinical concerns and cover arrangements for unavailable consultants.
  Stated by Manchester University NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  The Trust concluded that regular Consultant reviews occurred and junior doctors escalated clinical concerns as required in Mrs Ross’ case.
  Stated by Manchester University NHS Foundation TrustDisputes the concern
AI-generated summary

Evelyn Ross · 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

Evelyn Ross fractured her hip, underwent surgery, and was transferred for rehabilitation. After a fall, delayed CT scanning identified an acute on chronic subdural haematoma, followed by surgery, deterioration with hospital-acquired pneumonia, and her death on 23 September 2019. Concerns included staffing shortages, delays arranging discharge care, inadequate documentation, failure to follow the falls risk policy, and a lack of clear regular orthogeriatric consultant reviews and escalation when her condition deteriorated.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to escalate deterioration to a consultant
Wider context from the report
“5. There did not appear to be a clear system of regular orthogeriatric consultant reviews of Mrs Ross. This meant that there was no escalation of her condition to a consultant when she began to show signs of deterioration. ”
Source location
Evelyn Ross · 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 daily and twice-weekly Consultant in Care of the Elderly reviews, with escalation to senior medical staff for clinical concerns and cover arrangements for unavailable consultants.

Verbatim wording from the response
“The Consultants in Care of the Elderly/Geriatricians at Trafford General Hospital input daily at the morning Board Rounds and all patients are discussed and followed up to Consultant level as needed. If clinical concerns are raised in respect of an individual patient’s case, a member of the Senior Medical team (Consultant or Registrar) will review the patient.”

Source location
2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Page 9 · response
Published 5 June 2020
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 Trust concluded that regular Consultant reviews occurred and junior doctors escalated clinical concerns as required in Mrs Ross’ case.

Verbatim wording from the response
“Having undertaken a comprehensive review of the entries in Mrs Ross’ clinical notes, the Consultant team at Trafford General Hospital have been able to establish that in Mrs Ross’ case there were in fact regular Consultant reviews, in line with required standards, and there was no issue in respect of junior doctor escalation, which as documented in the clinical notes took place as required. I apologise if the evidence you heard at the Inquest did not accurately convey this.”

Source location
2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Page 9 · response
Published 5 June 2020
Open published response
22 Apr2020
Manchester South
Concerns raised1
1. Lack of nursing observation charts for recognising acute illness or deterioration
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement and use NEWS scoring, NEWS2 observation charts, and adult sepsis assessment and guidance tools.
  Stated by RMD Care Services Ltd t/a Lynmere Nursing HomeStated completed
2. Action
  Provide one-to-one instruction to nursing staff on using the NEWS and sepsis tools.
  Stated by RMD Care Services Ltd t/a Lynmere Nursing HomeStated completed
3. Action
  Ensure newly recruited and agency nursing staff are informed about using and the importance of the NEWS and sepsis tools.
  Stated by RMD Care Services Ltd t/a Lynmere Nursing HomeStated completed
AI-generated summary

Norman Baxter · 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

Norman Baxter was admitted to hospital after becoming unwell at Lynmere Nursing Home on 7 August 2019 and died in hospital the following day. The inquest found that he died as a consequence of complications of Chronic Obstructive Pulmonary Disease and an E. coli infection, with severe sepsis and septic shock also identified. A concern was raised that nursing observation charts were not in use at Lynmere, which may have assisted staff in recognising acute illness or deterioration.

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 nursing observation charts for recognising acute illness or deterioration
Wider context from the report
“1. The court heard evidence that, at the time Mr Baxter was cared for at Lynmere, nursing observation charts were not in use. Nursing observation charts, when completed, may assist staff in appreciating an acute episode of illness, or deterioration in a resident’s condition. This may particularly be the case were the observation chart to be used in conjunction with a system such as NEWS2, an aggregate scoring system intended to standardise the assessment of, and response to acute illness. ”
Source location
Norman Baxter · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement and use NEWS scoring, NEWS2 observation charts, and adult sepsis assessment and guidance tools.

Verbatim wording from the response
“I wish to advise that following the Inquest, a discussion between myself and ████████ ████████ the previous manager took place and the following was put into place with immediate effect.”

Source location
2020-0098-Response-from-Lynmere-Nursing-Home_Redacted
Page 1 · response
Published 18 May 2020
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 one-to-one instruction to nursing staff on using the NEWS and sepsis tools.

Verbatim wording from the response
“This was followed up by one to one discussions with all our Nursing staff confirming their understanding of how to use the tools.”

Source location
2020-0098-Response-from-Lynmere-Nursing-Home_Redacted
Page 1 · response
Published 18 May 2020
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
Ensure newly recruited and agency nursing staff are informed about using and the importance of the NEWS and sepsis tools.

Verbatim wording from the response
“████████ the acting manager has also been made aware of the contents of the Regulation 28 report and I wish to confirm that these tools are being used and that any new nursing staff recruited since have also been made aware. Any agency staff that work at Lynmere are also advised of the use of these tools and their importance.”

Source location
2020-0098-Response-from-Lynmere-Nursing-Home_Redacted
Page 1 · response
Published 18 May 2020
Open published response
21 Feb2020
Mid Kent and Medway
Concerns raised1
1. Oxygen-saturation monitoring failing to detect deterioration when oxygen levels do not deplete
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Update paediatric guidelines to strengthen recognition, senior assessment, monitoring and management of children with myopathies and hypokalaemia, including STRS contact indications.
  Stated by Medway NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  NICE considers existing general guidance on assessment, monitoring, and altering care as indicated appropriate.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
AI-generated summary

LUKE OWEN JACKSON · 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

Luke Owen Jackson, who had Becker’s Muscular Dystrophy and a chest infection, was admitted to hospital on 4 December 2019 and suffered a cardiac arrest on 6 December before being transferred to the Evelina Children’s Hospital. He later died on palliative care from hypoxic ischaemic encephalopathy following prolonged cardiac arrest. The principal concerns included recognition and treatment of total-body potassium depletion in a child with myopathy, and the limitations of monitoring oxygen saturation when assessing deterioration.

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
Oxygen-saturation monitoring failing to detect deterioration when oxygen levels do not deplete
Wider context from the report
“The Trust has taken action to address the conclusions of its Root Cause Analysis and has learned and disseminated lessons, improving its processes. This Report is made to assist learning in the public interest as evidence was heard from a consultant from a specialist children’s hospital that total body potassium depletion is not always recognised in children with myopathies who become unwell. They may present with diarrhoea and vomiting due to shunting of the blood away from the gut to protect vital organs such as the brain and heart. (1) Luke had complex needs and was awaiting results of genetic testing confirmed as Becker’s Muscular Dystrophy. He had not been eating and drinking, had loose stools and vomiting that had progressed over a five-day period in a background of a chest infection. His parents had sought and followed medical advice from the hospital by telephone. Luke continued to deteriorate, and he was admitted. The Trust took some steps on admission to address his low potassium. (2) Evidence was heard from a Consultant from the Evelina Children’s Hospital that they get almost 2000 referrals a year and many have diarrhoea and vomiting as a first symptom. Issues relating to metabolic derangement in a child with myopathies is not always recognised as total body potassium depletion and that treatment may need to be undertaken in intensive care due to the increased amounts of potassium required to correct the derangement and manage clinical risks: (i) Children with Myopathies - have low muscle mass that compromises their ability to correct their own potassium levels when unwell. (ii) Luke had a chest infection, however his low potassium made him weaker and as it progressed, he was shunting blood away from his gut to compensate (this assists to protect the vital organs such as the heart and brain) which resulted in loose stools and vomiting; this was not a consequence of gastroenteritis. One of the early symptoms of this shunting process is a high heart rate. (iii) A bolus of potassium and fluid resuscitation to treat gastroenteritis was not sufficient to treat total body potassium depletion which requires a central line with significant potassium replacement in intensive care to manage clinical risk. (iv) Development of a chest infection requires a child to breath harder and this becomes more difficult in a child with myopathies that is already weakened due to low potassium and will not present with the usual symptoms of respiratory distress. (v) As Luke was treated with oxygen therapy, the monitor alarm set for oxygen saturations did not sound as his oxygen did not deplete and he went into cardiac arrest ”
Source location
LUKE OWEN JACKSON · 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
Update paediatric guidelines to strengthen recognition, senior assessment, monitoring and management of children with myopathies and hypokalaemia, including STRS contact indications.

Verbatim wording from the response
“The Trust has updated their Paediatric Guidelines (GUDPCM016) in response to patients with myopathies to reflect that:”

Source location
2021-0052-Response-from-Medway-Maritime-Hospital-Redacted
Page 2 · response
Published 1 March 2021
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
NICE considers existing general guidance on assessment, monitoring, and altering care as indicated appropriate.

Verbatim wording from the response
“It is the view of NICE that the current general guidance about assessment, monitoring, and altering care as indicated is appropriate.”

Source location
2021-0052-Response-from-Dept-of-Health-and-Social-Care-Redacted
Page 2 · response
Published 1 March 2021
Open published response
28 Jan2020
Northamptonshire
Concerns raised1
1. Failure to provide senior doctor review for deteriorating patients
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Ratify and implement an updated ED standard operating policy defining responsibility for each patient and escalation arrangements.
  Stated by Kettering General Hospital NHS Foundation TrustStated completed
2. Action
  Increase daily senior decision-making capacity by adding middle-grade shifts and a second consultant shift in the Emergency Department.
  Stated by Kettering General Hospital NHS Foundation TrustStated completed
3. Action
  Create a new EDU operating policy specifying consultant ward-round responsibility, patient ownership and risks identified in the report before recommissioning.
  Stated by Kettering General Hospital NHS Foundation TrustStated planned
AI-generated summary

Susan Sterland · 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

Susan Sterland was brought to Kettering General Hospital on 29 December 2018 with an intestinal obstruction that was not diagnosed, and was admitted after being diagnosed with constipation. Her condition deteriorated, care was not escalated, and she collapsed and died early on 31 December 2018. The principal concern was that she was not seen by a senior doctor despite deterioration and remaining in hospital for about 40 hours; the report states that earlier senior review might have led to investigation and earlier diagnosis.

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 senior doctor review for deteriorating patients
Wider context from the report
“This was obviously a very busy time at the hospital. However, Ms Sterland was in the hospital for some 40 hours, she was not getting better, there were signs that she was deteriorating during the late morning and afternoon of 30 December, there was a plan to admit her to a ward but there were no beds available. My concern is that in this situation she was not seen by a senior doctor. If Ms Sterland had been seen by a senior doctor the evidence was that she would have had further investigation which would have led to earlier diagnosis of the obstruction and may have altered the outcome. The evidence at the inquest suggested that there are some categories of patients in the emergency department for whom a senior review is mandatory. It may be that the Trust would wish to consider whether the circumstances of this case suggest that there are other situations in which a senior review should be required. ”
Source location
Susan Sterland · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Ratify and implement an updated ED standard operating policy defining responsibility for each patient and escalation arrangements.

Verbatim wording from the response
“1. A revision to the Standard Operating Practice to set out who is responsible for reviewing patients:”

Source location
2020-0062-Response-from-Kettering-General-Hospital_Redacted
Page 2 · response
Published 20 March 2020
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
Increase daily senior decision-making capacity by adding middle-grade shifts and a second consultant shift in the Emergency Department.

Verbatim wording from the response
“The Department medical rota has been changed to increase the number of senior decision makers present within the department on each day. As a result the number of middle-grade shifts has been increased from 9 to 11 shifts, daily. In addition, the number of consultants in the department has been increased by adding a second consultant shift from 15:00 to 22.00 and we are aiming to have 2 consultants in ED from 08:00 to 22.00. This will allow a timely senior review of patients and will provide consultant ward rounds for EDU.”

Source location
2020-0062-Response-from-Kettering-General-Hospital_Redacted
Page 2 · response
Published 20 March 2020
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
Create a new EDU operating policy specifying consultant ward-round responsibility, patient ownership and risks identified in the report before recommissioning.

Verbatim wording from the response
“The EDU was decommissioned in March 2020 in response to Covid 19. The area where EDU was located is currently being used as ED Major cubicles which are part of the ED footprint.”

Source location
2020-0062-Response-from-Kettering-General-Hospital_Redacted
Page 2 · response
Published 20 March 2020
Open published response
28 Nov2019
Inner North London
Concerns raised1
1. Failure of ambulance service callers to recognise further patient deterioration when calling from a different location
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Christina Lawal · 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

Christina Lawal, who had type 2 diabetes and attended hospital regularly for dialysis, developed abdominal pain at home after returning from dialysis on 23 January 2019. She deteriorated, went into cardiac arrest shortly after paramedics arrived, and her death was confirmed at 23.05. The concerns included the absence of a cordless telephone for making emergency calls and the risk that ambulance triage callers may not provide accurate or updated information when they are not with the patient.

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 ambulance service callers to recognise further patient deterioration when calling from a different location
Wider context from the report
“3) Callers to the ambulance service may not be aware of further deterioration in a patient’s condition if they are calling from a different location. ”
Source location
Christina Lawal · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Nov2019
West Yorkshire Eastern
Concerns raised1
1. Failure to recognise the need to advance a planned C-section through close monitoring of a high-risk pregnancy
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Serena Jane Nicholas · 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

Serena Jane Nicholas was born by category 1 emergency Caesarean section on 29 August 2017 after fetal bradycardia and died shortly afterwards at Leeds General Infirmary from intrauterine hypoxia, with the pregnancy also involving a diabetic mother and a fetal heart abnormality. Concerns included disjointed management and a lack of identified consultants overseeing the high-risk pregnancy, as well as inadequate continuity of care and monitoring, meaning reduced fetal activity and the potential desirability of an earlier Caesarean section were not recognised.

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 the need to advance a planned C-section through close monitoring of a high-risk pregnancy
Wider context from the report
“(2) The tertiary centre where the C-section (and the subsequent open heart surgery envisaged) were to take place, were not aware that the baby had been inactive for some days before the planned C-section (because the mother had not reported this and had not had contact with clinicians since the clinical appointment with a community midwife on 24/08/17). In consequence, a serious adverse development went unheeded until symptoms crossed on the eve of the C-section. In view of the history of the pregnancy continuity of care and close monitoring of a high risk pregnancy led to a situation in which the desirability of advancing the C-section by say, a week, was not recognised. ”
Source location
Serena Jane Nicholas · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to escalate deteriorating postoperative patients to senior clinicians

Lack of clear escalation procedures and training for deteriorating postoperative patients

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Concerns raised1

Failure to respond appropriately to deterioration while patients remain on discharge wards

Concerns raised2

Failure to recognise serious and deteriorating medical conditions

Delays in organising medical assistance for serious deterioration

Concerns raised1

Failure to inform the GP of patient deterioration

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to escalate deterioration to a consultant

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of nursing observation charts for recognising acute illness or deterioration

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Oxygen-saturation monitoring failing to detect deterioration when oxygen levels do not deplete

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 6

Actions described in response 3

Actions described in response 1

Respondent positions 1

Actions described in response 3

Actions described in response 1

Respondent positions 1