Recurring concern

Failure to reliably recognise and treat raised intracranial pressure promptly

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First reported 9 Jul 2014•Latest report 7 Jan 2021

Definition

What this concern includes

Includes failures in the dedicated clinical process for recognising, assessing, escalating or promptly treating raised intracranial pressure, including failure to recognise relevant clinical signs, inadequate guidance for intracranial bleeding or pressure after falls, and delay in treatment while the underlying diagnosis is being established.

Not included

Excludes generic delays in assessment or treatment where raised intracranial pressure is not a material part of the asserted concern.
Excludes general head-injury pathway failures where raised intracranial pressure is not the specific unsafe condition.
Excludes opioid, anticoagulant or other medication-management failures unless they directly concern recognition or treatment of raised intracranial pressure.
Excludes failures occurring after raised intracranial pressure has been reliably recognised and treated when the remaining issue is unrelated downstream care.

Reports: 3
Individual concerns: 3
Date range: 2014–2021
Stated actions: 4

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.

National Institute for Health and Care Excellence2

Cwm Taf Morgannwg University Local Health Board1

Prince Charles Hospital (Merthyr Tydfil)1

Shaw Healthcare Limited1

Specsavers Optical Group Limited1

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.

7 Jan2021
Gwent
Concerns raised1
1. Failure to consider unequal pupils alone as a sign of increased intracranial pressure due to a bleed or aneurysm
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.
Actions described in response 2
1. Action
  Commission a specialist optometrist or neuro-ophthalmologist to develop training materials on this presentation.
  Stated by SpecsaversStated in progress
2. Action
  Record and disseminate the specialist training through an online webinar or similar mechanism for Company professional staff.
  Stated by SpecsaversStated planned
AI-generated summary

John BERROW · Prevention of Future Deaths report

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

Report summary

On 11 October 2019, John Berrow attended an optician with unequal pupils and altered eyesight, was referred routinely to an eye hospital, then collapsed later that day and died in hospital. His death was attributed to a ruptured Berry aneurysm. Concerns included failure to recognise unequal pupils as a possible sign of intracranial bleeding or aneurysm, the lack of practical clinical reference tools, and the absence of a mechanism for sharing learning from clinical incidents among practitioners at Specsavers.

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 consider unequal pupils alone as a sign of increased intracranial pressure due to a bleed or aneurysm
Wider context from the report
“████████ gave oral evidence at the inquest hearing. In evidence he admitted that he failed to consider unequal pupils alone as a sign of increased intracranial pressure due to a bleed or aneurysm and has rectified this in his current practice. ”
Source location
John BERROW · 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
Commission a specialist optometrist or neuro-ophthalmologist to develop training materials on this presentation.

Verbatim wording from the response
“This was an unusual presentation. We appreciate the importance of sharing experience and learning across the Company. We are liaising with Specsavers Professional Training team to commission a specialist optometrist or neuro-ophthalmologist to deliver training materials (concentrating on this topic) which will be recorded and disseminated via an online webinar or other similar mechanism which will be available to all Professional staff within the Company. We also hope to make the training available for the wider optical community outside the Company so that there is an opportunity for non-Specsavers practitioners to learn and any and all matters arising out of Mr Berrow’s sad death.”

Source location
2021-0080-Response-from-Specsavers-Redacted
Page 1 · response
Published 30 March 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Record and disseminate the specialist training through an online webinar or similar mechanism for Company professional staff.

Verbatim wording from the response
“This was an unusual presentation. We appreciate the importance of sharing experience and learning across the Company. We are liaising with Specsavers Professional Training team to commission a specialist optometrist or neuro-ophthalmologist to deliver training materials (concentrating on this topic) which will be recorded and disseminated via an online webinar or other similar mechanism which will be available to all Professional staff within the Company. We also hope to make the training available for the wider optical community outside the Company so that there is an opportunity for non-Specsavers practitioners to learn and any and all matters arising out of Mr Berrow’s sad death.”

Source location
2021-0080-Response-from-Specsavers-Redacted
Page 1 · response
Published 30 March 2021
Open published response
19 Jun2019
West Sussex
Concerns raised1
1. NICE guidelines inadequately addressing slow intracranial bleeding after falls in elderly patients
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 2
1. Action
  Conduct the ongoing surveillance review of the head injury guideline to determine whether it requires updating.
  Stated by National Institute for Health and Care ExcellenceStated in progress
2. Action
  Publish the final surveillance review decision in September 2019.
  Stated by National Institute for Health and Care ExcellenceStated planned
Respondent positions 3
1. Position
  NICE guidelines do not apply to the organisation, so it will not undertake work to address their adequacy.
  Stated by Shaw Healthcare LimitedOutside remit
1. Position
  The Chief Executive of NICE is responsible for responding to concerns about the adequacy of NICE guidelines.
  Stated by Shaw Healthcare LimitedRedirects responsibility
2. Position
  Existing NICE head-injury guidance already applies to injuries caused by both direct and indirect trauma.
  Stated by National Institute for Health and Care ExcellenceDisputes the concern
AI-generated summary

James William Francis · 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

James William Francis, who had a history of falls and balance difficulties, suffered an unwitnessed fall at his care home on 9 April 2017 and later developed repeated vomiting and deterioration. He was admitted to hospital with a large subdural haematoma and died on 11 April 2017. The principal concerns included failures in shift handover and monitoring, delays in seeking medical advice, inadequate information provided to paramedics, the patient’s positioning, staff training, and whether relevant guidelines sufficiently addressed this type of injury in elderly patients.

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
NICE guidelines inadequately addressing slow intracranial bleeding after falls in elderly patients
Wider context from the report
“The suggestion was that the existing guidelines may not sufficiently address the fact that this type of slow bleed fall in the elderly also needs to be considered i.e non-traumatic head injury leading to a shearing effect on the brain. The suggestion was that this type of slow bleed may take significantly longer to manifest in terms of observable symptoms such as a change in alertness or persistent vomiting. It certainly seems that the care home staff did not make the connection As a result, this raises concerns as to whether this type of incident which must be frequent in the elderly is adequately taken into account in relevant NICE guidelines ”
Source location
James William Francis · 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
Conduct the ongoing surveillance review of the head injury guideline to determine whether it requires updating.

Verbatim wording from the response
“The guideline is currently undergoing a surveillance review exercise to determine whether it should be updated. As a result of your report, the review is likely to conclude that an update is required so that it is clearer that the guideline applies to indirect head injury (for example, by making the definition more accessible to users). A final surveillance review decision is due to be published in September 2019.”

Source location
2019-0202-Response-by-NICE
Page 1 · response
Published 23 August 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
Publish the final surveillance review decision in September 2019.

Verbatim wording from the response
“The guideline is currently undergoing a surveillance review exercise to determine whether it should be updated. As a result of your report, the review is likely to conclude that an update is required so that it is clearer that the guideline applies to indirect head injury (for example, by making the definition more accessible to users). A final surveillance review decision is due to be published in September 2019.”

Source location
2019-0202-Response-by-NICE
Page 1 · response
Published 23 August 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
NICE guidelines do not apply to the organisation, so it will not undertake work to address their adequacy.

Verbatim wording from the response
“6) Adequacy of NICE guidelines - which do not apply to ourselves, we note that a response is required from the Chief Executive of NICE. We will of course fully work to any revisited set of NICE guidelines.”

Source location
2019-0202-Response-by-Shaw-Healthcare
Page 1 · response
Published 23 August 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
The Chief Executive of NICE is responsible for responding to concerns about the adequacy of NICE guidelines.

Verbatim wording from the response
“6) Adequacy of NICE guidelines - which do not apply to ourselves, we note that a response is required from the Chief Executive of NICE. We will of course fully work to any revisited set of NICE guidelines.”

Source location
2019-0202-Response-by-Shaw-Healthcare
Page 1 · response
Published 23 August 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
Existing NICE head-injury guidance already applies to injuries caused by both direct and indirect trauma.

Verbatim wording from the response
“We have considered the circumstances surrounding Mr Francis’ death and the concerns raised in your report and in particular the concerns that existing NICE guidance on head injury may not be appropriate for instances where a person experiences a non-direct head trauma.”

Source location
2019-0202-Response-by-NICE
Page 1 · response
Published 23 August 2019
Open published response
9 Jul2014
Cardiff & the Vale of Glamorgan
Concerns raised1
1. Delays in treating raised intracranial pressure while awaiting diagnosis
This report raised 11 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

Thomas George Smith · Prevention of Future Deaths report

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

Report summary

Thomas George Smith, aged 13, developed symptoms including headache, neck pain and vomiting before being admitted to hospital, where he later became unresponsive and died after suspected meningitis and raised intracranial pressure. The report identified concerns about delays in recognising and treating meningitis and raised intracranial pressure, communication and handover, responding to nursing concerns, monitoring physiological trends, and the transfer of the patient to hospital.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in treating raised intracranial pressure while awaiting diagnosis
Wider context from the report
“(4) It appeared at the inquest if the clinicians had adopted an “exclusionary focus” to rule out meningitis rather than an “inclusionary focus” so as to be able to adopt a diagnosis of meningitis as a differential diagnosis. The Coroner considers that the inclusionary approach is appropriate where a patient presents with some of the signs of meningitis. It should be standard practice at PCH for raised Intracranial pressure to be treated without delay even if a diagnosis is awaited on the underlying condition. ”
Source location
Thomas George Smith · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to consider unequal pupils alone as a sign of increased intracranial pressure due to a bleed or aneurysm

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.2

Concerns raised1

NICE guidelines inadequately addressing slow intracranial bleeding after falls in elderly 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.2

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

Concerns raised1

Delays in treating raised intracranial pressure while awaiting diagnosis

Actions described in response 2

Actions described in response 2

Respondent positions 3