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 Jun2025
East London
Concerns raised1
1. Failure of the Critical Care Outreach Team to attend A&E for deteriorating patients
This report raised 8 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.
Respondent positions 2
1. Position
  CCOT cannot currently review acutely unwell, undifferentiated Emergency Department patients because it lacks the required skills and resources.
  Stated by Barts Health NHS TrustUnable to act
1. Position
  A critical care in-reach registrar with consultant intensivist access provides responsive Emergency Department support, although it does not replace full CCOT presence.
  Stated by Barts Health NHS TrustExisting arrangements considered sufficient
AI-generated summary

Mrs Norma Faye Campbell · 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 Norma Faye Campbell attended Whipps Cross Hospital emergency department on 13 January 2024 with clear signs of sepsis and died there in the early hours of 14 January 2024 after suffering a cardiac arrest. The report identifies delays and omissions in sepsis treatment, monitoring, fluid resuscitation and escalation of care. It also raises concerns about overcrowding, inadequate staffing and facilities, insufficient resuscitation beds, lack of electronic observations and the absence of Critical Care Outreach Team support in the emergency department.

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 the Critical Care Outreach Team to attend A&E for deteriorating patients
Wider context from the report
“5. The Critical Care Outreach Team (CCOT) do not currently attend A&E for deteriorating patients. The overcrowding and lack of resourcing in A&E highlights the need for the CCOT to provide support to A&E patients as well as patients on the ward. ”
Source location
Mrs Norma Faye Campbell · 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
CCOT cannot currently review acutely unwell, undifferentiated Emergency Department patients because it lacks the required skills and resources.

Verbatim wording from the response
“We would like to acknowledge and address the concern raised about the absence of a formal CCOT presence in the Emergency Department. CCOT do not currently have the skill set or resource to review acutely unwell and undifferentiated patients within the emergency department. An extended period of training would be required which will need to be determined by local service needs and referenced to outreach services that have successfully implemented this. However, we recognise the importance of timely critical care input and have alternative arrangements to ensure support is available when needed. The current pathway is that the critical care in-reach registrar, who is assigned for reviewing patients outside of intensive care unit, is available to attend the ED, this registrar has access to a consultant intensivist at any”

Source location
Response from Barts Health NHS Foundation Trust
Page 4 · response
Published 26 June 2025
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
A critical care in-reach registrar with consultant intensivist access provides responsive Emergency Department support, although it does not replace full CCOT presence.

Verbatim wording from the response
“We would like to acknowledge and address the concern raised about the absence of a formal CCOT presence in the Emergency Department. CCOT do not currently have the skill set or resource to review acutely unwell and undifferentiated patients within the emergency department. An extended period of training would be required which will need to be determined by local service needs and referenced to outreach services that have successfully implemented this. However, we recognise the importance of timely critical care input and have alternative arrangements to ensure support is available when needed. The current pathway is that the critical care in-reach registrar, who is assigned for reviewing patients outside of intensive care unit, is available to attend the ED, this registrar has access to a consultant intensivist at any”

Source location
Response from Barts Health NHS Foundation Trust
Page 4 · response
Published 26 June 2025
Open published response
4 Mar2025
Sunderland
Concerns raised1
1. Failure to recognise 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 1
1. Action
  Refresh ECG-reading competency for all non-registered Healthcare Professionals through assessment and continuing professional development.
  Stated by The Nerams GroupStated completed
AI-generated summary

Jack Matthew Shields · 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

Jack Matthew Shields, a 29-year-old man with extensive heart conditions, experienced shortness of breath at home and died on 28 April 2024 after deteriorating into cardiac arrest despite resuscitation attempts. The report raises concerns about the delayed ambulance response and the failure to recognise his deteriorating condition and request the highest-priority backup.

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 patient deterioration
Wider context from the report
“The evidence was clear that Jack’s condition at the time of the first ambulance arrival at 00:36am was such that a higher priority backup should have been requested. Jack was symptomatic of cardiogenic shock with descending blood pressures, shortness of breath, nausea and vomiting, and required the highest priority backup of Cat 1 (Peri Arrest). I am concerned that the crew should have recognised the deteriorating condition when considering relevant observations such as ECG interpretation, an early recognition of such a deterioration and a correct categorisation of a backup request may have led to rapid stabilisation and transportation to definitive care. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”
Source location
Jack Matthew Shields · 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
Refresh ECG-reading competency for all non-registered Healthcare Professionals through assessment and continuing professional development.

Verbatim wording from the response
“Lessons learned were identified throughout the course of the investigation, immediate mitigation to ensure that all non-registered Healthcare Professionals who read 12 lead ECGs have refreshed competency through assessment and CPD has been implemented as well as information circulated to all staff to highlight the various categories of backup available as well as the appropriateness of each.”

Source location
Response from The Nerams Group
Page 1 · response
Published 7 March 2025
Open published response
19 Feb2025
Staffordshire and Stoke-on-Trent
Concerns raised1
1. Failure to promptly review and escalate deteriorating patients
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 1
1. Action
  Review and amend policies and procedures for reviewing, escalating and referring deteriorating patients.
  Stated by University Hospitals of North Midlands NHS TrustStated in progress
Respondent positions 3
1. Position
  A team approach, supported by flexible staffing and specialist support, is considered more effective than assigning a Named Nurse in the resuscitation area.
  Stated by NHS EnglandExisting arrangements considered sufficient
1. Position
  The Trust does not consider that insufficient nursing staff caused the failure to recognise Philip’s deterioration.
  Stated by NHS EnglandDisputes the concern
2. Position
  The Trust is responsible for providing further comments and information on actions taken since the inquest concerning the Coroner’s concerns.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Philip John UNWIN · 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

Philip John Unwin, aged 68, was admitted to hospital with fever, shortness of breath and chest pain, and was later confirmed to have sepsis secondary to pneumonia. His condition deteriorated while he remained in the Emergency Department resuscitation area, and he died in hospital on 3 April 2024 from multi-organ failure secondary to pneumonia. Concerns included delayed medical review and escalation to intensive care, staffing in the resuscitation area not complying with national guidance, and recommendations from an internal investigation not having been acted upon in this respect.

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 promptly review and escalate deteriorating patients
Wider context from the report
“Although the conclusion of the inquest was one of Natural Causes there was evidence of a failure for medical teams to respond to concerns that the patient was deteriorating whilst awaiting assessment in the resuscitation area of the Emergency Department of Royal Stoke University Hospital. It was accepted by witnesses from the hospital that the patient should not have deteriorated to a 'moribund' state within that area of the hospital when concerns had been raised by staff and family, and that review and escalation to intensive care should have been initiated sooner (albeit the evidence was that this did not more than minimally contribute to the death). As a result of the concerns raise by hospital staff regarding missed opportunities to escalate care in a timely manner the hospital undertook a Patient Safety Incident Investigation (PSII). As a result of that investigations a number of recommendations were made with assurances given to the report author that work is being undertaken to review and amend policies and procedures focused on reviewing, escalating and referring deteriorating patients. However, the inquest was told that although the Emergency Department Resuscitation area was where the illest patients were placed awaiting review, staffing levels were not in compliance with national guidance. The Royal College of Emergency Medicine (RCEM) “Nursing Workforce Standards for Type 1 Emergency Departments” (Appendix 5) states “There will be a minimum of Registered Nurse to each patient in the resuscitation area”. The recommendation continued that there should be a named nurse allocated to each patient which should be 1:1 as per National Guidance. The concern is that the current model of staffing within the Emergency Department Resus area is not in compliance with national guidance and the recommendations following internal investigation into the care afforded to the deceased have not been acted upon in this respect. ”
Source location
Philip John UNWIN · 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
Review and amend policies and procedures for reviewing, escalating and referring deteriorating patients.

Verbatim wording from the response
“As a result of the concerns raised by hospital staff regarding missed opportunities to escalate care in a timely manner the hospital undertook a Patient Safety Incident Investigation (PSII). As a result of that investigations a number of recommendations were made with assurances given to the report author that work is being undertaken to review and amend policies and procedures focused on reviewing, escalating and referring deteriorating patients.”

Source location
Response from Royal Stoke University Hospital
Page 2 · response
Published 21 February 2025
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
A team approach, supported by flexible staffing and specialist support, is considered more effective than assigning a Named Nurse in the resuscitation area.

Verbatim wording from the response
“UHNM advise that having a Named Nurse in the ED has been tried previously at the Royal Stoke University Hospital, but a ‘team approach’ has been found to work better in the Resuscitation area of the ED rather than care falling to one medical professional. Trauma patients are always nursed 1:1 and this is due to the professional judgement required and the ability to flex staff around the department and into resuscitation with the support of an Operating Department Practitioner (ODP), the (supernumerary) Nurse in Charge and any outreach support for trauma calls. UHNM have asked us to note that the PSII identified that there was clear escalation by relevant nursing staff, and that it is not their belief that a lack of nursing staff led to the failure to recognise Philip’s deterioration.”

Source location
Response from NHS England
Page 2 · response
Published 21 February 2025
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 does not consider that insufficient nursing staff caused the failure to recognise Philip’s deterioration.

Verbatim wording from the response
“UHNM advise that having a Named Nurse in the ED has been tried previously at the Royal Stoke University Hospital, but a ‘team approach’ has been found to work better in the Resuscitation area of the ED rather than care falling to one medical professional. Trauma patients are always nursed 1:1 and this is due to the professional judgement required and the ability to flex staff around the department and into resuscitation with the support of an Operating Department Practitioner (ODP), the (supernumerary) Nurse in Charge and any outreach support for trauma calls. UHNM have asked us to note that the PSII identified that there was clear escalation by relevant nursing staff, and that it is not their belief that a lack of nursing staff led to the failure to recognise Philip’s deterioration.”

Source location
Response from NHS England
Page 2 · response
Published 21 February 2025
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 is responsible for providing further comments and information on actions taken since the inquest concerning the Coroner’s concerns.

Verbatim wording from the response
“It is appropriate that UHNM provide any further comment regarding the Coroner’s concerns. It is NHS England’s understanding that they will be providing further information on actions taken by the Trust since the inquest into Philip’s death in their response to the Coroner.”

Source location
Response from NHS England
Page 2 · response
Published 21 February 2025
Open published response
18 Feb2025
Gwent
Concerns raised1
1. Failure to revise ambulance priority when a patient is deteriorating and in extremis
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
  Establish a national group of clinical and operational leads to review measures for incidents outside the purple and red categories.
  Stated by Welsh GovernmentStated in progress
2. Action
  Undertake a review of whether measures are required for incidents outside the purple and red categories, including relevant amber conditions.
  Stated by Welsh GovernmentStated planned
3. Action
  Seek assurance at the next integrated quality planning and delivery meeting on call categorisation and provision of clinically appropriate responses.
  Stated by Welsh GovernmentStated planned
Respondent positions 2
1. Position
  Welsh Ministers do not deliver health services or make WAST’s operational decisions on emergency ambulance call categorisation.
  Stated by Welsh GovernmentOutside remit
1. Position
  WAST is responsible for operational emergency ambulance call categorisation and is best placed to respond to required action.
  Stated by Welsh GovernmentRedirects responsibility
AI-generated summary

Jeffrey Martin Tyler · 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

Jeffrey Martin Tyler called emergency services with chest pains and difficulty breathing, but his condition deteriorated while he was alone at home. An ambulance arrived several hours later, and his death was confirmed by paramedics on 20 February 2024. The substantive concern was that, despite his deterioration and being alone and in extremis, the emergency call remained categorised as Amber 1, with a reported waiting time of between 5 and 7 hours.

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 revise ambulance priority when a patient is deteriorating and in extremis
Wider context from the report
“In evidence I found that the call handlers had been following the correct algorithm as dictated by the nationally adopted Medical Priority Dispatch System (MPDS), and that he was appropriately categorised as requiring an Amber 1 ambulance. However, it would also have been clear to any clinician that he was deteriorating and was in the process of having a cardiac event. Mr Tyler was on his own and could not inform the ambulance service if his condition deteriorated. Despite Mr Tyler being alone and being in extremis, the MPDS Code was maintained at Amber 1. The waiting time was between 5 and 7 hours. ”
Source location
Jeffrey Martin Tyler · 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
Establish a national group of clinical and operational leads to review measures for incidents outside the purple and red categories.

Verbatim wording from the response
“Over the next two months, a review will be undertaken to consider whether measures are required for incidents not categorised in the purple or red categories. This will include conditions which currently fall in the ‘amber’ category such as symptoms of a stroke or heart attack. To drive the review, we are establishing a national group of clinical and operational leads to review and consider measures for these conditions. WAST will consider the findings of this additional review before finalising changes to its clinical model.”

Source location
Response from Welsh Government
Page 3 · response
Published 20 February 2025
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
Undertake a review of whether measures are required for incidents outside the purple and red categories, including relevant amber conditions.

Verbatim wording from the response
“Over the next two months, a review will be undertaken to consider whether measures are required for incidents not categorised in the purple or red categories. This will include conditions which currently fall in the ‘amber’ category such as symptoms of a stroke or heart attack. To drive the review, we are establishing a national group of clinical and operational leads to review and consider measures for these conditions. WAST will consider the findings of this additional review before finalising changes to its clinical model.”

Source location
Response from Welsh Government
Page 3 · response
Published 20 February 2025
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
Seek assurance at the next integrated quality planning and delivery meeting on call categorisation and provision of clinically appropriate responses.

Verbatim wording from the response
“I hold the Chair of WAST to account for oversight of the delivery of those expectations through regular meetings. Officials also hold the Chief Executive Officer and his executive team to account through bimonthly integrated quality planning and delivery (IQPD) meetings where progress against key performance targets is scrutinised and assurance on the quality and safety of services is sought. I have asked officials to seek assurance on the process of categorisation of calls and steps taken by the Trust to ensure service users receive the right response for their clinical need at the next IQPD meeting to be held on 24 April 2025.”

Source location
Response from Welsh Government
Page 2 · response
Published 20 February 2025
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
Welsh Ministers do not deliver health services or make WAST’s operational decisions on emergency ambulance call categorisation.

Verbatim wording from the response
“However, it is important to note, that the Welsh Ministers are not responsible for the delivery of health services in Wales. Instead, Local Health Boards (LHBs) are responsible for planning, commissioning and delivering services for the population of its area and NHS Trusts are responsible for the delivery of services across Wales within the national policy framework set by the Welsh Ministers.”

Source location
Response from Welsh Government
Page 1 · response
Published 20 February 2025
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
WAST is responsible for operational emergency ambulance call categorisation and is best placed to respond to required action.

Verbatim wording from the response
“The Welsh Ambulance Services National Health Service Trust (Establishment) Order 1998 establishes the Welsh Ambulance Services University National Health Service Trust (WAST). Article 3 delegates the function of managing the ambulance service to WAST.”

Source location
Response from Welsh Government
Page 2 · response
Published 20 February 2025
Open published response
13 Dec2024
Essex
Concerns raised3
1. Delays in escalating deteriorating maternity patients for senior and critical care review
2. Failure to recognise covert bleeding causing hypovolaemia
3. Failure to consider bleeding as a cause of maternal deterioration
This report raised 13 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 9
1. Action
  Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.
  Stated by Royal College of Obstetricians and GynaecologistsStated completed
2. Action
  Provide guidance defining circumstances requiring consultant attendance in acute obstetric and gynaecological care, including maternal collapse and major haemorrhage.
  Stated by Royal College of Obstetricians and GynaecologistsStated completed
3. Action
  Teach and practise SBAR escalation during annual multidisciplinary PROMPT training.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
1. Action
  Launch the RCOG escalation toolkit, including AID language, conflict-resolution teaching and team-of-shift handover practices.
  Stated by Mid and South Essex NHS Foundation TrustStated planned
2. Action
  Implement the OBS UK obstetric bleeding care bundle covering risk assessment, quantitative blood-loss measurement, escalation, and rapid clotting tests.
  Stated by Mid and South Essex NHS Foundation TrustStated in progress
3. Action
  Implement the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
4. Action
  Embed deterioration recognition, concealed-bleeding assessment and escalation training in PROMPT, induction, local teaching, drills and written staff communications.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
5. Action
  Adopt a rota requiring junior registrars to pair with senior registrars and establish supervision and risk-mitigation arrangements when the intended skill mix is unavailable.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
6. Action
  Provide guidance on maternal collapse, including early-warning observation, systematic cause identification, ongoing assessment and concealed-haemorrhage diagnosis.
  Stated by Royal College of Obstetricians and GynaecologistsStated completed
AI-generated summary

LAURA-JANE KIRSTEN NICOLE SEAMAN · 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

Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 following a massive intra-abdominal haemorrhage after a recent vaginal delivery, with subsequent disseminated intravascular coagulation. The principal concerns were failures to recognise and escalate maternal collapse and hypovolaemia, obtain and record vital signs and blood-test results, examine for covert bleeding, activate the major haemorrhage protocol, and provide appropriate senior review. The inquest concluded that her death was avoidable and contributed to by neglect.

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
Delays in escalating deteriorating maternity patients for senior and critical care review
Wider context from the report
“(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect. (3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs. (4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet. (5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach team. ”
Source location
LAURA-JANE KIRSTEN NICOLE SEAMAN · 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 recognise covert bleeding causing hypovolaemia
Wider context from the report
“(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect. (3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs. (4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet. (5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach team. ”
Source location
LAURA-JANE KIRSTEN NICOLE SEAMAN · 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 consider bleeding as a cause of maternal deterioration
Wider context from the report
“(6) The Trust Executive Review Group (“ERG”) Report was not shared with the Trust Director of Midwifery or the Head of Midwifery at Broomfield Hospital who did not agree with the ERG conclusions that: ‘The absence of escalation to an obstetric consultant was discussed and noted that the team escalated to an anaesthetist, which is usual practice in an obstetric emergency (putting out a call to the medical emergency team would not be common practice).’ ‘The possible reasons why the bleeding was not identified were discussed and it was noted that in maternity cases the absence of vaginal bleeding and with no signs of uterine rupture it would be unlikely that the team would have considered bleeding as a cause of deterioration.’ and gave evidence that this is not in accordance with good clinical practice or national guidelines and training. ”
Source location
LAURA-JANE KIRSTEN NICOLE SEAMAN · 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
Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.

Verbatim wording from the response
“The RCOG’s clinical guidance in this context includes the following:”

Source location
Response from Royal College of Obstetricians and Gynaecologists
Page 3 · response
Published 18 December 2024
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 guidance defining circumstances requiring consultant attendance in acute obstetric and gynaecological care, including maternal collapse and major haemorrhage.

Verbatim wording from the response
“5. Good Practice Paper on Roles and responsibilities of the consultant providing acute care in obstetrics and gynaecology⁹ states that one of the general situations in which the consultant must attend is any return to theatre for obstetrics or gynaecology. Some of the other obstetrics reasons for attendance are early warning score protocol or sepsis screening tool that suggests critical deterioration where HDU / ITU care is likely to become necessary or maternal collapse or where ‘major obstetric haemorrhage’ call has been instigated.”

Source location
Response from Royal College of Obstetricians and Gynaecologists
Page 4 · response
Published 18 December 2024
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
Teach and practise SBAR escalation during annual multidisciplinary PROMPT training.

Verbatim wording from the response
“The obstetric, midwifery and anaesthetic teams have yearly Practical Obstetric Multi Professional Training (PROMPT) training sessions as an MDT where they role play emergency scenarios. Since Laura-Jane’s death, during PROMPT, the teams are taught about the SBAR tool, (Situation, Background, Assessment, Recommendation). Escalation via the use of the SBAR tool is practiced teaching the quality and effectiveness of good communication. SBAR is an easy to remember mechanism to use to frame communications or conversations. It is a structured way of communicating information that requires a response from the receiver. As such, SBAR can be used very effectively to escalate a clinical problem that requires immediate attention, or to facilitate efficient handover of patients between clinicians or clinical teams.”

Source location
Response from Mid & South Essex NHS Trust
Page 3 · response
Published 18 December 2024
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
Launch the RCOG escalation toolkit, including AID language, conflict-resolution teaching and team-of-shift handover practices.

Verbatim wording from the response
“As part of the Each Baby Counts initiative, the maternity service is launching the Royal College of Obstetricians and Gynaecologists’ (RCOG) ‘Escalation Toolkit’ in February 2025. This toolkit is designed to enhance escalation and improve patient safety and consists of three key components:”

Source location
Response from Mid & South Essex NHS Trust
Page 3 · response
Published 18 December 2024
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 the OBS UK obstetric bleeding care bundle covering risk assessment, quantitative blood-loss measurement, escalation, and rapid clotting tests.

Verbatim wording from the response
“Since August 2024, the maternity unit at Broomfield hospital has begun the implementation of a new obstetric bleeding strategy. The strategy works alongside current PROMPT recommendations of managing a postpartum haemorrhage already in place at the maternity unit.”

Source location
Response from Mid & South Essex NHS Trust
Page 4 · response
Published 18 December 2024
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 the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.

Verbatim wording from the response
“The service identified these issues in the initial review of the incident. Since Laura-Jane’s death there has been an implementation of a new MEWS package with escalation policy. This includes the trigger response/medical emergency team once a score of 7 or above is reached.”

Source location
Response from Mid & South Essex NHS Trust
Page 6 · response
Published 18 December 2024
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
Embed deterioration recognition, concealed-bleeding assessment and escalation training in PROMPT, induction, local teaching, drills and written staff communications.

Verbatim wording from the response
“7) An ‘unwell woman’s’ simulation based on antepartum and postpartum haemorrhage including uterine rupture, abruption, and Vasa Previa, as well as a separate simulation on an anaphylaxis scenario was included in the 2023 PROMPT maternity training for all staff in addition to Human factors training, teamwork, situational awareness, and escalation.”

Source location
Response from Mid & South Essex NHS Trust
Page 8 · response
Published 18 December 2024
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
Adopt a rota requiring junior registrars to pair with senior registrars and establish supervision and risk-mitigation arrangements when the intended skill mix is unavailable.

Verbatim wording from the response
“We now have a new rota system in place where the required staffing establishment must include a junior registrar paired with a senior registrar. The junior then has a point of escalation to ensure that any MEWS score of four or above is escalated to the senior registrar and onto the Consultant.”

Source location
Response from Mid & South Essex NHS Trust
Page 11 · response
Published 18 December 2024
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 guidance on maternal collapse, including early-warning observation, systematic cause identification, ongoing assessment and concealed-haemorrhage diagnosis.

Verbatim wording from the response
“2. Maternal Collapse in Pregnancy and the Puerperium⁴ (Green-top Guideline No. 56). Clearly states that: “An obstetric modified early warning score chart should be used for all women undergoing”

Source location
Response from Royal College of Obstetricians and Gynaecologists
Page 3 · response
Published 18 December 2024
Open published response
3 Dec2024
Inner North London
Concerns raised1
1. Failure to escalate observed clinical deterioration to the healthcare team
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.

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

Mnayea ZMF Al Basman · 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

Mnayea ZMF Al Basman, who had significant co-morbidities, underwent a right hemicolectomy for caecal adenocarcinoma and died in hospital on 25 March 2024 after developing sepsis and peritonitis caused by an anastomotic leak. Concerns included failure to escalate aspects of his deterioration to the consultant surgeon, insufficient professional curiosity, inadequate overnight observation planning, and a lack of detail in some records. The report also noted that the events preceding his death had not been subject to an internal investigation, providing little reassurance that these matters had been addressed.

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 observed clinical deterioration to the healthcare team
Wider context from the report
“1) The consultant colorectal surgeon was not in the hospital over the weekend of 23/24 March 2024; however, he was able to be contacted if the need arose. The consultant surgeon noted the following matters in relation to the care provided to Mr Al Basman over that weekend: • a further CT scan could have been indicated, particularly given issues with Mr Al Basman’s drain, albeit there was nothing to indicate that any scan was needed on an urgent basis; • some entries in the clinical notes may have been ‘falsely reassuring’; • the physiotherapist who saw Mr Al Basman on the morning of 24 March 2024, noted that he appeared to be ‘declining’ but there was no evidence that this was escalated this to someone within the healthcare team; • there was a degree of insufficient professional curiosity on the part of some clinicians who saw Mr Al Basman; and • there should have been a plan in place to closely observe Mr Al Basman overnight on 24/25 March 2024. 2) Based on the above, the consultant surgeon formed the view that Mr Al Basman’s clinical presentation should have led to the consultant being informed and consulted, but it did not. 3) A number of the notes/records in relation to the care provided to Mr Al Basman, particularly over the weekend of 23/24 March 2024, lacked detail. Given that the events preceding Mr Al Basman’s death have not been the subject of an internal investigation, I received little, if any, reassurance that these matters have been addressed. ”
Source location
Mnayea ZMF Al Basman · Prevention of Future Deaths report
Page 2 · concerns
Open source report
4 Sep2024
Cheshire
Concerns raised1
1. Failure to alert a doctor to significant deterioration before discharge home
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.
Respondent positions 2
1. Position
  Existing policy-based escalation was considered sufficient because observations did not warrant medical review before discharge.
  Stated by Stockport NHS Foundation TrustExisting arrangements considered sufficient
1. Position
  The Trust disputes that significant deterioration was identified on discharge, citing a NEWS of zero throughout the admission.
  Stated by Stockport NHS Foundation TrustDisputes the concern
AI-generated summary

Charles Henry DANIELS · 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

Charles Henry Daniels was admitted to Stepping Hill Hospital in January 2024 after a fall and was later discharged home in March despite being described as clearly unwell. He returned to hospital with an acute on chronic subdural bleed and died on 21 March 2024. Concerns included inadequate nursing record-keeping, failure to alert a doctor to his deterioration before discharge, and the distress caused by his condition and discharge arrangements at home.

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 alert a doctor to significant deterioration before discharge home
Wider context from the report
“2) Neither the discharging nurse nor North West Ambulance Service personnel attending Stepping Hill on 6 March 2024, for the purposes of his discharge home, appear to have alerted a doctor to the significant deterioration in Mr Daniel’s condition since last assessed by a doctor on 4 March. ”
Source location
Charles Henry DANIELS · 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
Existing policy-based escalation was considered sufficient because observations did not warrant medical review before discharge.

Verbatim wording from the response
“████████ has further reviewed the record and has confirmed that Mr Daniels’ vital observations did not warrant any escalation to the medical team at any point from 4 March”

Source location
Response from Stepping Hill Hospital
Page 1 · response
Published 31 October 2024
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 disputes that significant deterioration was identified on discharge, citing a NEWS of zero throughout the admission.

Verbatim wording from the response
“On the day of discharge, the Ward Sister recalls that Mr Daniels required the assistance of three to transfer but due to his variable requirements for assistance with mobility, this did not appear unduly out of character.”

Source location
Response from Stepping Hill Hospital
Page 2 · response
Published 31 October 2024
Open published response
15 Aug2024
Gwent
Concerns raised1
1. Failure to recognise deteriorating patients
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 5
1. Action
  Meet with the digital team to define the requirement and prioritise introducing electronic observations in the Emergency Department.
  Stated by Aneurin Bevan University LHBStated completed
2. Action
  Map Emergency Department processes and requirements to support electronic observation implementation.
  Stated by Aneurin Bevan University LHBStated completed
3. Action
  Develop an options appraisal identifying the safest, quickest and most cost-effective approach to electronic observations, including licensing and integration costs.
  Stated by Aneurin Bevan University LHBStated in progress
1. Action
  Obtain supplier quotations and prepare a capital bid while seeking funding prioritisation for the electronic observation project.
  Stated by Aneurin Bevan University LHBStated in progress
2. Action
  Introduce an electronic observation and NEWS recording system in the Emergency Department.
  Stated by Aneurin Bevan University LHBStated planned
AI-generated summary

Kay SIMMONDS · 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

Kay Simmonds attended hospital with signs of sepsis arising from an infected haemodialysis central line, developed septic shock, and died on 22 July 2022. Concerns included an incorrect NEWS score calculation, failure to refer her to a senior medical practitioner, observations not being performed in line with NEWS requirements, and her transfer to a hospital without an available ITU bed.

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 deteriorating patients
Wider context from the report
“Kay Simmonds was admitted to the Emergency Department of the Grange University Hospital on 21/7/2022. At 14:40 a nurse performed observations and calculated her NEWS score. However this calculation was incorrect. As a result Kay was not referred to a senior medical practitioner in line with the NEWS algorithm. Additionally, the observations were not thereafter performed in line with the NEWS requirements. The miscalculation of NEWS and failure to recognise a deteriorating patient can put lives at risk. ”
Source location
Kay SIMMONDS · 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
Meet with the digital team to define the requirement and prioritise introducing electronic observations in the Emergency Department.

Verbatim wording from the response
“The Urgent Care Division has met with the Health Board’s digital team on 29 August 2024 to discuss the requirement and urgency to introduce CareFlow within the ED, this is now a priority for the Division.”

Source location
Response from Aneurin Bevan University Health Board
Page 2 · response
Published 21 August 2024
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
Map Emergency Department processes and requirements to support electronic observation implementation.

Verbatim wording from the response
“Following the meeting, a member of the digital team attended the ED on 17 September 2024, to map the current processes and requirements and following this visit the digital team are developing an options appraisal to determine how the recording of electronic observations can be recorded within the ED.”

Source location
Response from Aneurin Bevan University Health Board
Page 2 · response
Published 21 August 2024
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 an options appraisal identifying the safest, quickest and most cost-effective approach to electronic observations, including licensing and integration costs.

Verbatim wording from the response
“Following the meeting, a member of the digital team attended the ED on 17 September 2024, to map the current processes and requirements and following this visit the digital team are developing an options appraisal to determine how the recording of electronic observations can be recorded within the ED.”

Source location
Response from Aneurin Bevan University Health Board
Page 2 · response
Published 21 August 2024
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
Obtain supplier quotations and prepare a capital bid while seeking funding prioritisation for the electronic observation project.

Verbatim wording from the response
“Digital team have made contact with the system suppliers and have received quotes for this work and have also prepared a capital bid and are seeking prioritisation of funding.”

Source location
Response from Aneurin Bevan University Health Board
Page 3 · response
Published 21 August 2024
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 electronic observation and NEWS recording system in the Emergency Department.

Verbatim wording from the response
“1. Action that will be taken to introduce an electronic observation and NEWS recording system within the Emergency Department (ED) at the Grange University Hospital (GUH)”

Source location
Response from Aneurin Bevan University Health Board
Page 1 · response
Published 21 August 2024
Open published response
12 Aug2024
Inner North London
Concerns raised1
1. Delays in recognising that patients are unrousable
This report raised 7 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
  Complete refresher Intermediate Life Support training for the nurse involved.
  Stated by East London NHS Foundation TrustStated planned
AI-generated summary

Nimo OSMAN · 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

Nimo Osman was in state detention under a Hospital Order and receiving psychiatric inpatient care when she collapsed on the ward on 21 April 2022. She was unresponsive for over half an hour before an ambulance was called and died in hospital on 23 April 2022 from hypoxic ischaemic brain injury. The principal concerns were delays in recognising the emergency and calling an ambulance, whether learning had been embedded among staff, completion of venous thromboembolism assessments, and ambiguity in the Trust’s venous thromboembolism policy.

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
Delays in recognising that patients are unrousable
Wider context from the report
“Following the discovery of Ms Osman’s collapse on Rosebank Ward on 21 April 2022, it took staff a significant number of minutes to recognise that instead of just lying on the floor, Ms Osman was actually unrousable. A few minutes later a nurse arrived on the scene, who decided to summon the duty senior nurse (DSN) by radio, rather than activating the alarm system, which would have summoned the rapid response team sooner. The DSN contacted the duty doctor to inform them that there was a medical emergency, prior to calling an ambulance. In total, Ms Osman had been on the floor and unresponsive for over half an hour before an ambulance was called. I also viewed the CCTV evidence covering this course of events. I heard evidence from a consultant neurosurgeon and a consultant neuroradiologist. Their evidence was such that, in Ms Osman’s case this delay would not have made a difference because she had suffered a catastrophic brain injury and her condition was likely to have been unsalvageable from the moment she was found unresponsive on the floor. However, I consider that a delay of circa 30 minutes in calling an emergency ambulance raises a considerable risk, if repeated in the case of another patient requiring emergency treatment at hospital. I was initially reassured by the evidence of a very senior member of nursing staff (Nurse A) about the work that has been done to educate all staff that anyone can call 999 for an ambulance if they consider it necessary, without seeking the advice of colleagues or the specific approval of a doctor. I was told by Nurse A that they were confident that the education and training undertaken with staff had had a positive impact and that a delay of this kind was unlikely to be repeated in the future. However, a senior nurse (Nurse B) who was on duty at the time of Ms Osman’s collapse told me in their evidence (over two years after Ms Osman’s death) that nursing staff cannot and would not call an ambulance of their own volition. Nurse B told me that she would only ever call an ambulance if told to do so by a more senior clinician. Nurse B went on to tell me that it was often the case that by the time an ambulance had been called and arrived, a patient would die; the manner in which this evidence was given led me to form the view that the Nurse B seemed to think that this was ‘just one of those things that happens’. While I was told by Nurse A (who seemed genuinely concerned) that this matter would be escalated and addressed, I was concerned that over two years since Ms Osman’s death this view was still held by a senior and experienced member of the nursing team who led a team of more junior nurses. My concern was such that I am not reassured that sufficient steps have been taken to prevent the recurrence of such a risk in the future. ”
Source location
Nimo OSMAN · 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
Complete refresher Intermediate Life Support training for the nurse involved.

Verbatim wording from the response
“5. I can confirm, that at the time of Ms Osman’s death and at the inquest, Nurse B’s Intermediate Life Support (ILS) training was up to date. This training is clear in highlighting the expectations of a staff member attending a medical emergency. These expectations include that the staff member will undertake an initial check of the service user, summons help internally, and ensure an ambulance is called. No permission is required from a senior staff member. Following the inquest, the BLN spoke to Nurse B and Nurse B confirmed that she recognised the need for escalation immediately in medical emergencies as opposed to waiting for senior input. The BLN and Nurse B agreed that Nurse B will complete refresher ILS training. In the meantime, Nurse B has also completed a reflective piece in relation to this matter.”

Source location
Response from East London Foundation Trust
Page 3 · response
Published 13 August 2024
Open published response
26 Jun2024
Inner North London
Concerns raised2
1. Delays in communicating and acting on urgent investigation instructions for deteriorating patients
2. Lack of clear protocols for escalation of deteriorating patients
This report raised 4 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 8
1. Action
  Reinforce urgent deterioration escalation through Resident Doctor communications, safety alerts, telephone or face-to-face consultant contact, and appropriate diagnostic-test ordering.
  Stated by HCA International Limited (trading as HCA Healthcare UKStated completed
2. Action
  Reinforce daily ward safety huddles for identifying deterioration and escalation needs, with complete handover to absent staff.
  Stated by HCA International Limited (trading as HCA Healthcare UKStated completed
3. Action
  Deliver Resident Doctor workshops covering escalation protocols, inquest learning, responsibilities, and responding to deteriorating patients.
  Stated by HCA International Limited (trading as HCA Healthcare UKStated completed
1. Action
  Empower ICU Nurses-in-Charge to escalate deteriorating patients to Resident Doctors and directly to Consultants when required.
  Stated by HCA International Limited (trading as HCA Healthcare UKStated completed
2. Action
  Reinforce Consultant-to-Consultant communication for urgent clinical matters and embed the expectation in Consultant practising-privileges policy.
  Stated by HCA International Limited (trading as HCA Healthcare UKStated completed
3. Action
  Revise and strengthen critical-care procedures defining escalation, record-keeping, communication, staffing, and medical-care responsibilities, and share them with relevant staff.
  Stated by HCA International Limited (trading as HCA Healthcare UKStated completed
4. Action
  Implement SBAR communication across clinical areas and audit its use and effectiveness through weekly clinical incident reviews.
  Stated by HCA International Limited (trading as HCA Healthcare UKStated completed
5. Action
  Update and distribute the Resident Doctor induction handbook to prohibit text messaging for urgent escalation and require telephone or face-to-face communication.
  Stated by HCA International Limited (trading as HCA Healthcare UKStated completed
AI-generated summary

Brian John COLBY · Prevention of Future Deaths report

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

Report summary

Brian Colby was an in-patient recovering from elective surgery and receiving treatment for aspiration pneumonia when he suffered a spontaneous catastrophic intracranial event on 16 September 2023; he died later that evening after being transferred for assessment and placed on a palliative care pathway. The principal concerns were delays and ineffective communication in recognising and escalating his deterioration, arranging an urgent CT scan, communicating clinical plans, and recording urgent matters. The report also raised concerns about unclear escalation and record-keeping procedures and whether further training had adequately addressed clinicians’ authority to initiate CT scan arrangements.

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
Delays in communicating and acting on urgent investigation instructions for deteriorating patients
Wider context from the report
“(5) The effective instruction to send Mr Colby for an urgent CT scan was at 13:19 on 16 September 2023, over two hours after an instruction for an urgent or as soon as possible CT head scan was given by a medical consultant (albeit it, this instruction was misunderstood) and over three hours after a CT head scan was first clinically indicated. This raises further concern in relation to communication and the escalation of deteriorating patients. The evidence was such that any delays in Mr Colby’s escalation and treatment were not causative of his death, but of course, that might not be the case for another patient. ”
Source location
Brian John COLBY · 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
Lack of clear protocols for escalation of deteriorating patients
Wider context from the report
“(1) At or about 10:00 on 16 September 2023, Mr Colby’s vital signs and observations showed a drop in his Glasgow Coma Score from 15/15 (at 09:00) to 11/15, and a clinically significant rise in his blood pressure. I heard evidence that this change in his vital signs and observations was enough to warrant requesting a CT scan to ascertain the cause or causes of the change in clinical presentation. Despite this, I found that this was not escalated as a cause for concern at the time. I heard that the on-call consultant for the intensive care unit (ICU) was not made aware of any deterioration in Mr Colby’s presentation until 12:42 that afternoon. The concern here is that there did not appear to be any, or any clear, protocol(s) in place for the escalation of a deteriorating patient. ”
Source location
Brian John COLBY · 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
Reinforce urgent deterioration escalation through Resident Doctor communications, safety alerts, telephone or face-to-face consultant contact, and appropriate diagnostic-test ordering.

Verbatim wording from the response
“1. Communications to all Resident Doctors as well as an Internal safety alert circulated reinforcing escalation protocols; when Resident Doctors are concerned about a deteriorating patient, these concerns must be escalated to the consultant responsible for the patient as soon as possible via a phone call or face to face conversation. We have ensured that all clinical departments have acknowledged the alert as being read and understood. | 20 June 2024; 10 July 2024 | Completed”

Source location
Response from HCA Healthcare
Page 4 · response
Published 28 June 2024
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
Reinforce daily ward safety huddles for identifying deterioration and escalation needs, with complete handover to absent staff.

Verbatim wording from the response
“We also have a Daily (every shift) ward “Safety Huddle” in line with HCA policy. The huddle discusses every patient on the ward and highlights specifically those patients that are high risk for deterioration as well as steps that should be taken should a patient require escalation.”

Source location
Response from HCA Healthcare
Page 3 · response
Published 28 June 2024
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
Deliver Resident Doctor workshops covering escalation protocols, inquest learning, responsibilities, and responding to deteriorating patients.

Verbatim wording from the response
“4. Roll out of Resident Doctors Workshops; These training workshops ran over 3 sessions throughout July 2024 for all Resident Doctors and included learning from Mr Colby’s inquest as well as a reiteration of all HCA protocols and policies relating to escalation and responding to the deteriorating patient. We have also reiterated the importance of escalating to a Consultant as soon as possible when a patient is noted to be deteriorating.”

Source location
Response from HCA Healthcare
Page 5 · response
Published 28 June 2024
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
Empower ICU Nurses-in-Charge to escalate deteriorating patients to Resident Doctors and directly to Consultants when required.

Verbatim wording from the response
“5. Within the ICU environment, we have emphasised to the Nurses-in-Charge the importance of escalating concerns from the bedside to Resident Doctors. It has also been reinforced to Nurses-in-Charge to ensure that Resident Doctors are supported to escalate as soon as possible all deteriorating patients to the Consultant. The Nurse-in-Charge is also empowered to escalate directly to the Consultant if required.”

Source location
Response from HCA Healthcare
Page 5 · response
Published 28 June 2024
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
Reinforce Consultant-to-Consultant communication for urgent clinical matters and embed the expectation in Consultant practising-privileges policy.

Verbatim wording from the response
“7. We have reinforced through the HCA Hospitals Medical Advisory Committee, the expectation that all communication related to urgent clinical matters is undertaken Consultant to Consultant, either face to face or via telephone. This has also been made specific within the Consultant Practicing Privileges policy which is provided to all Consultants to ensure that this practice remains embedded across HCA. All new Consultants are provided with this policy as part of their onboarding process and are required to adhere to this policy as part of their practice with HCA.”

Source location
Response from HCA Healthcare
Page 6 · response
Published 28 June 2024
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
Revise and strengthen critical-care procedures defining escalation, record-keeping, communication, staffing, and medical-care responsibilities, and share them with relevant staff.

Verbatim wording from the response
“3. We have revised and strengthened the Standard Operating Procedures for;”

Source location
Response from HCA Healthcare
Page 8 · response
Published 28 June 2024
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 SBAR communication across clinical areas and audit its use and effectiveness through weekly clinical incident reviews.

Verbatim wording from the response
“4. We have implemented a “Situation, Background, Assessment, Recommendation” (SBAR) communication tool across all clinical areas to assist staff in framing effective communications when escalating critical information. An audit has been implemented to monitor the use and effectiveness of the tool, the results of which will be reviewed and monitored via a weekly clinical incident review meeting attended by clinicians and senior Executives.”

Source location
Response from HCA Healthcare
Page 8 · response
Published 28 June 2024
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 and distribute the Resident Doctor induction handbook to prohibit text messaging for urgent escalation and require telephone or face-to-face communication.

Verbatim wording from the response
“1. We have updated the new Resident Doctor Induction Handbook to make it explicitly clear that escalation of a deteriorating patient must be undertaken via telephone call or face to face and that escalation via text message is not an appropriate form of communication to escalate urgent clinical concerns. This updated Handbook has been provided to all current Resident Doctors and will be provided to all new Resident Doctors in future. The Handbook will be regularly reviewed and updated going forward as required. | 31 July 2024 and on-going | Completed”

Source location
Response from HCA Healthcare
Page 10 · response
Published 28 June 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of the Critical Care Outreach Team to attend A&E for deteriorating patients

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to recognise 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.1

Concerns raised1

Failure to promptly review and escalate deteriorating 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.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to revise ambulance priority when a patient is deteriorating and in extremis

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised3

Delays in escalating deteriorating maternity patients for senior and critical care review

Failure to recognise covert bleeding causing hypovolaemia

Failure to consider bleeding as a cause of maternal 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.9

Respondent positions 2

Actions described in response 1

Actions described in response 1

Respondent positions 3

Actions described in response 3

Respondent positions 2

Actions described in response 9