Recurring concern

Failure to provide timely clinical care

First to latest report 28 Aug 2013 — 14 Jan 2026

Reports that mention this concern
17
Times this concern has been raised
17
Stated actions linked to this concern
22

What this concern includes

Includes delays or omissions in providing clinically required patient care, medical review or treatment where the delay can permit deterioration, worsen risk or reduce available treatment options, including the anchor's similar delays in patient care and delayed necessary treatment after recognition of a life-threatening condition.

What is not included
  • Excludes delays confined to a separately named clinical pathway, condition, service or operational process where that named concern provides the more specific supported boundary.
  • Excludes delays in ambulance attendance, hospital admission, specialist referral, diagnostic investigations or discharge when those processes are the specific unsafe condition rather than delayed clinical care generally.
  • Excludes failures to recognise deterioration where no delay in providing clinical care is identified.
  • Excludes delays caused solely by patient choice or clinically justified prioritisation where care remained within a safe timeframe.

Reports and published responses 17 reports

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

  1. Kent and Medway

    AI-generated summary

    Stephen Taylor · 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

    Stephen Taylor experienced worsening mental distress linked to work and financial concerns, with escalating risk indicators and repeated contact with health services. He died on 26 May 2025 after deliberately jumping from Louisa Bay Cliffs. The principal concerns were the lack of coordinated escalation and ownership of risk across services, reliance on his denial of immediate intent despite other risk indicators, routine rather than urgent referrals, and the absence of a same-day urgent face-to-face assessment despite family concerns.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to act on family-provided information indicating heightened and escalating risk

    Wider context from the report

    “(4) Family-provided information indicating heightened and escalating risk did not result in same-day escalation or urgent face-to-face clinical assessment. ”

    Source location

    Stephen Taylor · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver a two-day CRAM training event for Urgent Mental Health Helpline staff to improve risk recognition, risk curiosity and co-produced care and risk management planning.

    Verbatim wording from the response

    “With regard to improving risk recognition within the Kent & Medway Urgent Mental Health Helpline, the staff from this service are undergoing a 2-day Clinical Risk Assessment & Management (CRAM) training event to support improved risk recognition and risk curiosity, and to promote deeper questioning of patients who present with elevated risks and/or risk factors. This will include a focus on creation of a co-produced care and risk management plan.”

    Source location

    Response from Kent and Medway mental Health NHS Trust
    Page 2 · response
    Published 21 January 2026

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce visual prompts at every call station and workstation directing staff to arrange Rapid Response assessment within four hours when risk is concerning.

    Verbatim wording from the response

    “As a result of this very sad death, the Urgent Mental Health Helpline, has generated visual prompts at each call station to support clear identification and pathways for call handlers/clinicians to direct, where risk is of concern, a referral for a rapid assessment within 4 hours by our Rapid Response service. It is expected that our staff will not rely on a risk prompt tool but will be equipped to identify risk accurately and utilise a curious approach to seeking further risk information, from the patient, their families and referrers.”

    Source location

    Response from Kent and Medway mental Health NHS Trust
    Page 2 · response
    Published 21 January 2026

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Update the Duty Standard Operating Procedure to require same-day routine referral action and careful consideration of family members’ information.

    Verbatim wording from the response

    “• The Duty Standard Operating Procedure was reviewed and updated in November 2025 and now includes (1) an explicit reference to the management of routine referrals, and states these should be actioned on the day that the referral decision is made and consent received, and (2) reference to the importance of the careful consideration of family members’ information within the clinical decision-making process.”

    Source location

    Response from Vita Health Group
    Page 4 · response
    Published 21 January 2026

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver a reflective Duty Team session sharing case learning and the resulting Standard Operating Procedure changes.

    Verbatim wording from the response

    “• A reflective session with the Duty Team took place on 03/12/25 sharing the learning from this case and the changes that have made to the Duty Standard Operating Procedure as a result.”

    Source location

    Response from Vita Health Group
    Page 4 · response
    Published 21 January 2026

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    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    An urgent referral was not indicated because reported deterioration lacked evidence of dynamic risk, risky behaviour, suicide planning or intent.

    Verbatim wording from the response

    “Although Mr Taylor had not been reviewed directly by the clinical team, the Duty Team noted the concerns shared by his daughter, and agreed a plan with her, that a non-urgent referral was most appropriate and would be made to the Older Adult Mental Health Team. The rationale for this was that whilst Mr Taylor’s presentation had deteriorated and new risk factors had been reported, the absence of dynamic or immediate risk factors such as risky behaviour, or evidence of planning or intent towards a suicide attempt, meant that an urgent referral was not indicated and therefore unlikely to be accepted. However, due to an escalating presentation, additional support from the Older Adults Mental Health Team was still indicated.”

    Source location

    Response from Vita Health Group
    Page 3 · response
    Published 21 January 2026

    Open published response

  2. Inner North London

    AI-generated summary

    William David Patrick HEWES · 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

    William David Patrick HEWES was a fit and healthy young man who died from meningococcal septicaemia. Although his life-threatening condition was recognised immediately at hospital, he did not receive the necessary treatment as promptly as he should have, and the report identified a need to share the learning nationally.

    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 providing necessary treatment after recognition of a life-threatening condition

    Wider context from the report

    “William’s life threatening condition was recognised immediately he attended hospital, but he did not receive the necessary treatment as promptly as he should have done. The cause of the delay was multi factorial. ”

    Source location

    William David Patrick HEWES · 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

    Continue piloting Martha’s Rule, meeting other pilot sites and sharing implementation learning and data with NHS England.

    Verbatim wording from the response

    “1) The Trust are one of the pilot sites for the first phase in implementing Martha’s Rule. This is a major patient safety initiative providing patients and families with a way to seek an urgent review if they are concerned about a loved one’s deterioration. Part of this first phase is to help the NHS to devise and agree a standardised approach to all three elements of Martha’s Rule (ahead of scaling up to further sites in England in the following years). Once fully”

    Source location

    Response from Homerton University Hospital NHS Trust
    Page 1 · response
    Published 31 March 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver simulation training to clinical staff on closed-loop communication and direct instruction during emergency management of sepsis and shock.

    Verbatim wording from the response

    “2) One of our local actions was to deliver SIM (simulation) training to clinical staff. Simulation training is a tool used to gain practical experience, make informed decisions and refine their performance within controlled settings. The SIM training is focused on ensuring closed loop communication / direct instruction to team members when managing sepsis and shock in emergency situations. The plan is to develop this and deliver it on our Regional Trainee Teaching programme to resident doctors on managing human factors within healthcare. This course runs regularly throughout the year, we are aiming to incorporate the learning on closed loop communication into the next programme. The training runs 3 to 4 times a year.”

    Source location

    Response from Homerton University Hospital NHS Trust
    Page 2 · response
    Published 31 March 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and deliver closed-loop communication training for resident doctors through the Regional Trainee Teaching programme.

    Verbatim wording from the response

    “2) One of our local actions was to deliver SIM (simulation) training to clinical staff. Simulation training is a tool used to gain practical experience, make informed decisions and refine their performance within controlled settings. The SIM training is focused on ensuring closed loop communication / direct instruction to team members when managing sepsis and shock in emergency situations. The plan is to develop this and deliver it on our Regional Trainee Teaching programme to resident doctors on managing human factors within healthcare. This course runs regularly throughout the year, we are aiming to incorporate the learning on closed loop communication into the next programme. The training runs 3 to 4 times a year.”

    Source location

    Response from Homerton University Hospital NHS Trust
    Page 2 · response
    Published 31 March 2025

    Open published response

  3. Manchester South

    AI-generated summary

    Ernest Bacon · 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

    Ernest Thomas Bacon suffered an accidental fall at home, sustained a fractured neck of femur, and was admitted to Tameside General Hospital, where he subsequently had an ischaemic stroke. After triggering for sepsis on 16 January 2022, he was not reviewed face to face, the sepsis pathway was not followed, intravenous antibiotics were delayed, and the failure to escalate was not recognised. He died from sepsis at the hospital on 17 January 2022.

    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 further clinical review after continued sepsis triggers

    Wider context from the report

    “3. The Trust Policy required he be treated for Sepsis. However he was not placed on the Sepsis pathway and a further review did not take place until a further doctor was asked to examine him at about 22.30 despite his NEWS2 score continuing to trigger for Sepsis; ”

    Source location

    Ernest Bacon · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. South Yorkshire (Western)

    AI-generated summary

    Ann Pickering · 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

    Ann Pickering developed throat-swelling and choking complaints, was diagnosed with severe anxiety and an eating disorder, and was admitted to Kendray Hospital under a section of the Mental Health Act. She later deteriorated physically, was transferred to Barnsley Hospital, and died there on 1 July 2021. The substantive concerns included delays in recognising and inserting an NG tube, delayed acceptance of her transfer by Barnsley Hospital, and a lack of clear transfer policies and procedures for patients under a section.

    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 inserting required NG tubes

    Wider context from the report

    “During the inquest, evidence showed:- 1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required. 2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer 3. Despite recognising an NG tube was required, one was not inserted until the 30.6.21 4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them. ”

    Source location

    Ann Pickering · 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 the existing nutrition policy and agree nutritional-support and nasogastric-tube insertion requirements for detained patients, including restraint situations.

    Verbatim wording from the response

    “In addition to collaborative working between SWYPFT and BHNFT, a review of BHNFT’s existing nutrition policy and agreement on meeting a patient’s nutritional requirements particularly for detained patients, including where there is a need for restraint will be undertaken jointly.”

    Source location

    Response from NHS South West Yorkshire Partnership
    Page 2 · response
    Published 27 September 2022

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Put in place a standard operating procedure with timescales for timely nutritional support and clear cross-Trust responsibilities.

    Verbatim wording from the response

    “Nutritional support will be provided in a timely manner by staff from the respective Trusts being clear about their roles and responsibilities in their own organisations, and collectively so that delays do not arise. A standard operating procedure to clarify this along with clear timescales will be in place by 30 November 2022 (EXHIBIT 1).”

    Source location

    Response from NHS South West Yorkshire Partnership
    Page 2 · response
    Published 27 September 2022

    Open published response

  5. West Yorkshire Eastern

    AI-generated summary

    Alexander George Theodossiadis · 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

    Alexander George Theodossiadis, aged 25, died in hospital on 28 January 2020 after treatment for bacterial meningitis, a fall from a hospital bed, and a resulting head injury. Concerns included difficulty obtaining a timely GP appointment and insufficient symptom assessment, inadequate hospital transfer handover and care planning, uncertainty about meningitis management, and failure to assess or communicate his risk of falling.

    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

    Absence of directions specifying action timetables for life-threatening conditions

    Wider context from the report

    “(2) Mr Theodossiadis remained in A&E for some 10 hours in total, despite the nature of his condition. Concern was expressed at the Inquest in relation to firstly, the absence of clear instructions regarding the need for a lumbar puncture within four hours of admission; secondly, a clear pathway to an appropriate treatment location; thirdly, any directions specifying the timetable in which action was required in response to a life-threatening condition. ”

    Source location

    Alexander George Theodossiadis · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Black Country

    AI-generated summary

    Ms Karen Redding · 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

    Ms Karen Redding died after drinking an excess of Oramorph, becoming increasingly drowsy and suffering a fatal overdose. During the inquest, concern arose that care staff handed her the medication without checking the box contents, and that she was not seen by a doctor after disclosing that she had taken too much.

    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 arrange medical assessment after disclosed excess oramorph ingestion

    Wider context from the report

    “3. Although, she declined any help and said she would prefer to rest and “sleep it off”, it may well have been appropriate to have her seen by a Doctor. ”

    Source location

    Ms Karen Redding · 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

    Review and revise medication policies, procedures and working practices to prevent recurrence of medication-related incidents.

    Verbatim wording from the response

    “In the 19 years of Cherish providing care, no incident of this type has ever occurred. Management has reviewed the effectiveness of medication policies, procedures and working practices to ensure such circumstances are not repeated.”

    Source location

    2022-0133-Response-from-Cherish-Home-Care-Ltd_Published
    Page 3 · response
    Published 10 May 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement a medication-overdose procedure requiring staff to seek medical assistance regardless of service-user or next-of-kin agreement.

    Verbatim wording from the response

    “• On 25 March 2021 all records on the system were examined and an emergency office staff meeting was undertaken. During this meeting, we introduced the following procedure for where a medication overdose or a similar incident where the service user requires medical assistance, occurs –”

    Source location

    2022-0133-Response-from-Cherish-Home-Care-Ltd_Published
    Page 2 · response
    Published 10 May 2022

    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

    Disseminate the medical-assistance procedure to office staff through meetings and to care staff through refresher training and direct notifications.

    Verbatim wording from the response

    “2) All office staff were made aware of the procedure for seeking medical assistance discussed above, through staff meetings.”

    Source location

    2022-0133-Response-from-Cherish-Home-Care-Ltd_Published
    Page 3 · response
    Published 10 May 2022

    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 the medication-overdose policy and medical-assistance procedures to new staff through induction.

    Verbatim wording from the response

    “6) New staff will be introduced to the medication overdose policy and the procedures for seeking medical assistance through their induction process.”

    Source location

    2022-0133-Response-from-Cherish-Home-Care-Ltd_Published
    Page 3 · response
    Published 10 May 2022

    Open published response

  7. Inner North London

    AI-generated summary

    Stephen Francis WALKER · 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

    Stephen Francis Walker was admitted for an ileostomy reversal and developed vomiting and severe illness several days later. A nasogastric tube was not placed until that evening, and he died the following day after admission to intensive care. Concerns included delayed assessment and treatment, inadequate or missing records of clinical reviews and consent, and confusing medical records; the inquest found that earlier tube placement would have improved his chance of survival.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure timely medical review after deterioration and repeated requests

    Wider context from the report

    “1. Dr Walker’s condition had deteriorated by the time of the morning ward round on Easter Monday, 5 April 2021. He said that he felt awful and had begun vomiting. Dr Walker wondered if this was secondary to opiate analgesia, and this was recorded as the clinical impression. However, no record was put before me at inquest indicating that the clinical fellow undertaking the ward round conducted an abdominal examination, no subsequent early medical review was fixed and no nasogastric tube was passed. 2. At the morbidity and mortality meeting on 24 June, the registrar said that Dr Walker was offered a nasogastric tube but declined. However, I was told at inquest that there was no record of this. 3. I was told at inquest that, at lunch time on 5 April, nurses twice bleeped for a medical review, but there was no record that a medical review was undertaken, or that this was chased. ”

    Source location

    Stephen Francis WALKER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Norfolk

    AI-generated summary

    William Clifford ATHERTON · 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

    William Clifford Atherton was admitted to hospital on 29 May 2017 with abdominal symptoms, urinary retention and poor kidney function. He was discharged despite worsening renal function and deterioration, and died after returning severely unwell with vomiting of faecal matter, a distended abdomen and severe pain; the reported cause was bowel obstruction. Concerns included the lack of senior medical review and nursing observations, failure to recognise warning signs and worsening blood results, and inconsistent early warning score documentation and escalation.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide medical review after ward rounds

    Wider context from the report

    “That no medical review of Mr Atherton took place after the ward round on 30th. That his worsening condition was not recognised by the junior doctor reviewing the blood results. That no nursing observations were carried out in the several hours whilst he waited to go home and that potential warning signs of a bowel obstruction were not recognised and acted upon. His documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place. That the different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it. ”

    Source location

    William Clifford ATHERTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. South London

    AI-generated summary

    Julia Jane MacPherson · 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

    Julia Jane MacPherson, an informal patient of Oxleas NHS Foundation Trust, suffered swallowing difficulties and collapsed in the community with food bolus and vomitus in her throat; resuscitation was unsuccessful. Concerns included failure to arrange or undertake a timely medical review, failure to assess her mental capacity after concerns about confusion, incomplete clinical records, and prescribing and consent processes for off-licence medication. The inquest recorded the medical cause of death as upper airway obstruction associated with swallowing difficulties secondary to medication-related extrapyramidal symptoms.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide timely clinical review following reported deterioration

    Wider context from the report

    “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients. ”

    Source location

    Julia Jane MacPherson · 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

    Conducted a follow-up inspection of Oxleas NHS Foundation Trust’s acute wards to assess whether specific improvements had been made.

    Verbatim wording from the response

    “Since Julia Jane MacPherson's death in May 2016, we have inspected Oxleas NHS Foundation Trust once. This was a follow up inspection of the acute wards in the Trust, including Norman Ward, in February 2017 to see if some specific improvements had taken place since the comprehensive inspection in April 2016. We also carried out regular visits by our Mental Health Act reviewers, and the last one took place on Norman Ward in March 2017.”

    Source location

    2018-0298-Response-by-CQC
    Page 1 · response
    Published 19 January 2019

    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

    Return to inspect Oxleas NHS Foundation Trust and follow up the identified concerns to check that necessary improvements have been made.

    Verbatim wording from the response

    “We will be returning to inspect Oxleas NHS Foundation Trust later in the year. We intend to follow through some of the areas of concern in more detail. This will be to ensure the trust has learnt from this and made the necessary improvements.”

    Source location

    2018-0298-Response-by-CQC
    Page 2 · response
    Published 19 January 2019

    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

    Specific circumstances of Julia MacPherson’s individual care and treatment fall outside the regulator’s remit for comment.

    Verbatim wording from the response

    “We note our legal responsibility to submit a written response to you, however some of the matters of concern relate to the very specific circumstances of Julia MacPherson's individual care and treatment, so we are unable as a regulator to comment on this.”

    Source location

    2018-0298-Response-by-CQC
    Page 1 · response
    Published 19 January 2019

    Open published response

  10. Nottinghamshire

    AI-generated summary

    Elaine Bradbrook · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide clinical or nursing review after deterioration in consciousness

    Wider context from the report

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

    Source location

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

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Commence a serious incident investigation to review the care provided.

    Verbatim wording from the response

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

    Source location

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

    Open published response

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

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Data last updated 7 September 2026