Concerns raised 1
Failure to carry out regular blood tests View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Premiere Health Limited
Enforce the hospital discharge and clinical follow-up procedure, including review, action logging, GP confirmation and management audit.
View source
×
AI-generated summary
Pamela George · 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
Pamela George, aged 70, died at Derriford Hospital on 30 June 2023 after being urgently admitted with suspected sepsis. The report identified missed opportunities to carry out required blood tests, manage a breast infection, document and escalate a fall and medical concerns, assess and record capacity, and maintain relevant care-home policies and records.
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 carry out regular blood tests
Wider context from the report “1. Cann House missed an opportunity to carry out regular blood tests on Miss George between 23rd May and 29th June. These blood tests may have identified the need to continue to treat acute kidney injury which if left untreated may have affected her resilience to infection. The system for ensuring that discharge summaries are actioned was not available for me to see and I was not clear if any policy on this issue existed.
” Source location Pamela George · Prevention of Future Deaths report
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 Enforce the hospital discharge and clinical follow-up procedure, including review, action logging, GP confirmation and management audit.
Verbatim wording from the response “• The organisation has enforced its formal Hospital Discharge and Clinical Follow-Up Procedure, which includes:” Source location Response from Cann House
Open published response
23 Oct 2024 Jean THOMAS · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 1
Failure to monitor fluid balance View source
Linked response
Aneurin Bevan University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
Aneurin Bevan University LHB
Complete the review of Health Board documentation, monitoring tools and relevant national guidelines to establish an evidence base for best practice.
View source
Aneurin Bevan University LHB
Establish and operate a multidisciplinary Fluid Balance Task and Finish Group with defined improvement objectives.
View source
Aneurin Bevan University LHB
Initiate a surgical-ward fluid-balance monitoring pilot incorporating staff education, information boards, data sharing and auditing.
View source
Aneurin Bevan University LHB
Standardise fluid-balance monitoring documentation across the organisation.
View source
Aneurin Bevan University LHB
Explore using a digital observation platform to record fluid balance.
View source
Aneurin Bevan University LHB
Develop a multidisciplinary fluid-balance standard operating procedure.
View source
Aneurin Bevan University LHB
Disseminate expected fluid-balance monitoring standards through feedback sessions, posters, emails, ward meetings and learning events.
View source
Aneurin Bevan University LHB
Deliver strengthened multidisciplinary education and training on fluid-balance roles, responsibilities and best practice.
View source
Aneurin Bevan University LHB
Engage senior medical staff to support education and establish clinical expectations for fluid-balance monitoring.
View source
Aneurin Bevan University LHB
Incorporate Medical Examiner and Quality Safety Learning Forum learning into the fluid-balance improvement plan.
View source
Aneurin Bevan University LHB
Use the AMAT tool to standardise fluid-balance compliance audits, conduct audits through ward accreditation and report results to the Nutrition and Hydration Committee.
View source See 8 more actions
×
AI-generated summary
Jean THOMAS · 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
Jean Thomas fell at home, fractured her hip, underwent surgical fixation, developed post-operative sepsis, and died in hospital on 26 October 2023. The inquest found that her fluid balance was not monitored by nursing or medical staff despite heart failure, chronic renal failure, signs of acute kidney injury and sepsis; this was determined to be a failure in care and a grave concern.
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 monitor fluid balance
Wider context from the report “Jean was known to have significant cardiovascular problems and from her admission there were signs this was worsening.
Her blood pressure was low, which would normally be treated with intravenous fluids, but excess fluids would put more pressure on her heart, and thus she was also treated with a low dose of furosemide.
The management of Jean’s fluid balance was important for the following reasons; she had heart failure, she had chronic renal failure, she had signs of a superimposing acute kidney injury and she was scoring on the NEWS chart from admission, such that the algorithm required the fluid balance to be monitored. Jean had signs of sepsis.
I find at inquest that Jean’s fluid balance was not monitored , which I determined to be a failure in care. It was not monitored by the nursing or the medical staff . Whilst I could not find that knowledge of Jean’s fluid balance would have altered the outcome, it is a matter of grave concern that this basic nursing care was ignored , and these important clinical indicators not monitored by the medical staff .
” Source location Jean THOMAS · Prevention of Future Deaths report
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 the review of Health Board documentation, monitoring tools and relevant national guidelines to establish an evidence base for best practice.
Verbatim wording from the response “A review of current Health Board documentation and monitoring tools across the Region, alongside a review of recommended National Guidelines has taken place to provide the evidence base that will lead to best practice.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and operate a multidisciplinary Fluid Balance Task and Finish Group with defined improvement objectives.
Verbatim wording from the response “A Health Board Multidisciplinary Fluid Balance Task & Finish Group has formed with key objectives set which include:” Source location Response from Aneurin Bevan University Health Board
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 Initiate a surgical-ward fluid-balance monitoring pilot incorporating staff education, information boards, data sharing and auditing.
Verbatim wording from the response “A pilot project on fluid balance monitoring will be initiated on a surgical ward, incorporating education, information boards, and sharing and auditing of data. The pilot will evolve into a broader implementation project once the PDSA improvement tools demonstrate progress in the pilot area.” Source location Response from Aneurin Bevan University Health Board
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 Standardise fluid-balance monitoring documentation across the organisation.
Verbatim wording from the response “(1) Standardisation of Fluid Balance monitoring documentation across the organisation.
(2) Exploration of the possibility of utilising a digital observation platform to record fluid balance.
(3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure.
(4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events.
(5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.” Source location Response from Aneurin Bevan University Health Board
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 Explore using a digital observation platform to record fluid balance.
Verbatim wording from the response “(1) Standardisation of Fluid Balance monitoring documentation across the organisation.
(2) Exploration of the possibility of utilising a digital observation platform to record fluid balance.
(3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure.
(4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events.
(5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a multidisciplinary fluid-balance standard operating procedure.
Verbatim wording from the response “(1) Standardisation of Fluid Balance monitoring documentation across the organisation.
(2) Exploration of the possibility of utilising a digital observation platform to record fluid balance.
(3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure.
(4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events.
(5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.” Source location Response from Aneurin Bevan University Health Board
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 expected fluid-balance monitoring standards through feedback sessions, posters, emails, ward meetings and learning events.
Verbatim wording from the response “(1) Standardisation of Fluid Balance monitoring documentation across the organisation.
(2) Exploration of the possibility of utilising a digital observation platform to record fluid balance.
(3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure.
(4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events.
(5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.” Source location Response from Aneurin Bevan University Health Board
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 strengthened multidisciplinary education and training on fluid-balance roles, responsibilities and best practice.
Verbatim wording from the response “(1) Standardisation of Fluid Balance monitoring documentation across the organisation.
(2) Exploration of the possibility of utilising a digital observation platform to record fluid balance.
(3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure.
(4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events.
(5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.” Source location Response from Aneurin Bevan University Health Board
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 Engage senior medical staff to support education and establish clinical expectations for fluid-balance monitoring.
Verbatim wording from the response “Compliance with fluid balance monitoring and subsequent improvements will be incorporated into the work of the Nutritional and Hydration Committee. Senior medical staff will be engaged clinically to support education and establish clinical expectations. Learning from Medical Examiner feedback and the Quality Safety Learning Forum will be incorporated into the improvement plan.” Source location Response from Aneurin Bevan University Health Board
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 Incorporate Medical Examiner and Quality Safety Learning Forum learning into the fluid-balance improvement plan.
Verbatim wording from the response “Compliance with fluid balance monitoring and subsequent improvements will be incorporated into the work of the Nutritional and Hydration Committee. Senior medical staff will be engaged clinically to support education and establish clinical expectations. Learning from Medical Examiner feedback and the Quality Safety Learning Forum will be incorporated into the improvement plan.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the AMAT tool to standardise fluid-balance compliance audits, conduct audits through ward accreditation and report results to the Nutrition and Hydration Committee.
Verbatim wording from the response “The AMAT tool will be used to standardise the audit process for fluid balance compliance across the health board. Audits will be carried out in accordance with the Ward / Team Accreditation process and will be reported to the Nutrition & Hydration Committee.” Source location Response from Aneurin Bevan University Health Board
Open published response
4 Aug 2022 Malcolm John Garrett · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Insufficient monitoring of kidney function to avoid opiate toxicity View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Malcolm John Garrett · 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
Malcolm John Garrett, who was immunosuppressed following a bilateral lung transplant, was admitted with a vertebral fracture and subsequently developed pneumonia and other complications. He acquired Covid-19 while an inpatient and died at Stepping Hill Hospital on 23 September 2021; the direct causes were Covid pneumonitis and pseudomonas aeruginosa bronchopneumonia. The concerns included the absence of specific guidance for managing high-risk immunosuppressed patients, expediting discharge or using alternative treatment methods, and monitoring kidney function to avoid opiate toxicity.
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 Insufficient monitoring of kidney function to avoid opiate toxicity
Wider context from the report “3. His discharge was delayed in part due to opiate toxicity. That arose as a consequence of his kidneys not functioning correctly. The inquest heard evidence that to avoid opiate toxicity is such situations there needs to be a greater use of and understanding of the importance of monitoring kidney function .
” Source location Malcolm John Garrett · Prevention of Future Deaths report
Open source report
15 Jun 2022 Marjorie Walker · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of understanding and recognition of kidney-function monitoring alongside prescribing of pain medication View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Marjorie 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
Marjorie Walker was found unresponsive in hospital on 27 May 2020 after receiving prescribed gabapentin, morphine and buprenorphine, with post-mortem toxicology finding gabapentin above the therapeutic level. The report describes concerns about an incorrectly completed DNA CPR form, delays in specialist pain-clinic access, and insufficient recognition and monitoring of kidney function when prescribing gabapentin and other pain medication.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of understanding and recognition of kidney-function monitoring alongside prescribing of pain medication
Wider context from the report “3. Mrs Walker was prescribed Gabapentin as part of helping her to manage her chronic pain. The evidence was that the use of pain medication such as Gabapentin carried risk particularly in relation to a patient with underlying kidney issues. The inquest was told that a lack of understanding and recognition of monitoring kidney function including clearance results by health professionals including pharmacists and doctors alongside prescribing created a risk of overdose particularly of vulnerable patients. The inquest was told that the risk would be reduced by greater ease of access to results, more robust checking and education.
” Source location Marjorie Walker · Prevention of Future Deaths report
Open source report
14 Feb 2019 John Andrew Mellor · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1
Failure to ensure required blood tests for individuals under specialist secondary care for renal failure View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS Oldham CCG Northern Care Alliance NHS Foundation Trust Pennine Care NHS Foundation Trust St Chads Medical Practice
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 12
Northern Care Alliance NHS Foundation Trust
Modify patient letters to explain blood-test arrangements clearly and provide an SRFT contact for monitoring difficulties.
View source
Northern Care Alliance NHS Foundation Trust
Ask GPs before ESA treatment whether they can monitor bloods, record responses electronically, agree monitoring plans, and follow up non-responses.
View source
Northern Care Alliance NHS Foundation Trust
Assume responsibility for taking bloods until the GP responds, ensuring clinically necessary ESA treatment can begin.
View source
Northern Care Alliance NHS Foundation Trust
Develop and implement a standard operating policy covering ESA blood-monitoring arrangements, outstanding responses, and negative responses.
View source
Northern Care Alliance NHS Foundation Trust
Update the electronic record to track ESA blood results due, missing results requiring follow-up, and the latest haemoglobin results.
View source
Northern Care Alliance NHS Foundation Trust
Allocate prescriber job-plan time for ESA monitoring and prescribing.
View source
Northern Care Alliance NHS Foundation Trust
Write to existing ESA patients to identify difficulties accessing monitoring and manage identified difficulties under the agreed policy.
View source
Northern Care Alliance NHS Foundation Trust
Explore a Greater Manchester commissioned shared-care protocol for ESA monitoring through CCGs and the Medicines Management Group.
View source
NHS Oldham CCG
Establish an operating procedure requiring direct GP communication and a provider response before confirming monitoring-dependent treatment plans.
View source
NHS Oldham CCG
Describe the shared-care model in a business case for consideration by the Greater Manchester Medicines Management Group and local commissioners.
View source
NHS Oldham CCG
Identify patients receiving or potentially requiring shared-care ESA pathways and write to GP practices to promote robust monitoring.
View source
St Chads Medical Practice
Notify the CCG that the Practice was asked to monitor a red-status medication and report the associated significant event.
View source See 9 more actions
×
AI-generated summary
John Andrew Mellor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Andrew Mellor had diabetes mellitus, chronic kidney disease and deep vein thrombosis, and died on 3 October 2018 after collapsing at home following the discovery of a very low blood count requiring urgent transfusion. The report describes repeated difficulties in arranging required blood tests, with responsibility passed between agencies and no clear shared-care or testing arrangement. It also raises concern that communications about referrals and test requests were not sent directly to primary care, relying instead on the patient to pass on vital information.
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 ensure required blood tests for individuals under specialist secondary care for renal failure
Wider context from the report “That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure . Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility .
The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe.
It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly, with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider.
” Source location John Andrew Mellor · Prevention of Future Deaths report
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 Modify patient letters to explain blood-test arrangements clearly and provide an SRFT contact for monitoring difficulties.
Verbatim wording from the response “Immediate actions to assure patient safety
The wording of letters to patients has been modified to ensure the options available to them for arranging blood tests is very clear and a point of contact at SRFT is provided if the patient is having any difficulty. Patients may attend the renal clinics at Salford, Wigan, Bolton and Oldham for pre-arranged blood tests.” Source location 2019-0053-Responses
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 Ask GPs before ESA treatment whether they can monitor bloods, record responses electronically, agree monitoring plans, and follow up non-responses.
Verbatim wording from the response “Prior to commencement of treatment, a letter is now sent to the patient’s GP when the Renal Consultant is considering ESA treatment to make the GP aware of this and to ask if they are able to monitor the patient’s bloods. A return slip is included so that this can be completed and administered efficiently. When SRFT are aware of the GP’s position in respect of the patient’s bloods, an appropriate blood monitoring plan is agreed with the patient at the time of the prescription of ESA. This method enhances the informed consent process for ESA treatment as patients will have an understanding of the full implications of the monitoring required. SRFT’s Electronic Patient Record System (“EPR”) has been updated with a section confirming when a GP has responded in respect of monitoring. If no response is obtained from primary care, this is followed up by the renal clinical team.” Source location 2019-0053-Responses
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 Assume responsibility for taking bloods until the GP responds, ensuring clinically necessary ESA treatment can begin.
Verbatim wording from the response “Until SRFT receives a response from the GP, we assume responsibility for taking bloods to ensure that patients start ESA treatment when clinically necessary.
A Standard Operating Policy has been developed which describes the above process and the steps taken when a negative response is received, or when a response is outstanding. A copy of the Standard Operating Policy is attached.” Source location 2019-0053-Responses
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 and implement a standard operating policy covering ESA blood-monitoring arrangements, outstanding responses, and negative responses.
Verbatim wording from the response “Until SRFT receives a response from the GP, we assume responsibility for taking bloods to ensure that patients start ESA treatment when clinically necessary.
A Standard Operating Policy has been developed which describes the above process and the steps taken when a negative response is received, or when a response is outstanding. A copy of the Standard Operating Policy is attached.” Source location 2019-0053-Responses
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the electronic record to track ESA blood results due, missing results requiring follow-up, and the latest haemoglobin results.
Verbatim wording from the response “In order to track all patients receiving ESAs, SRFT’s EPR system has been updated to show when patients’ blood results are due, and those that are missing and require follow up.
Prescribers have allocated time in their job plans for ESA monitoring and prescribing. The new EPR system always shows the most recent haemoglobin results for the patient.” Source location 2019-0053-Responses
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 Allocate prescriber job-plan time for ESA monitoring and prescribing.
Verbatim wording from the response “In order to track all patients receiving ESAs, SRFT’s EPR system has been updated to show when patients’ blood results are due, and those that are missing and require follow up.
Prescribers have allocated time in their job plans for ESA monitoring and prescribing. The new EPR system always shows the most recent haemoglobin results for the patient.” Source location 2019-0053-Responses
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 Write to existing ESA patients to identify difficulties accessing monitoring and manage identified difficulties under the agreed policy.
Verbatim wording from the response “These improvements will provide assurance not only in respect of new patients who start ESA treatment, but also current patients. All patients currently receiving ESA treatment will be written to by the renal admin team by the end of May 2019 to establish whether they have experienced any difficulties in accessing appropriate monitoring. Patients experiencing difficulties will be managed in accordance with the agreed SOP.” Source location 2019-0053-Responses
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 Explore a Greater Manchester commissioned shared-care protocol for ESA monitoring through CCGs and the Medicines Management Group.
Verbatim wording from the response “As above, following discussions with the CCG, it is recognised that this is a Greater Manchester issue. We are exploring via the CCGs and the Greater Manchester Medicines Management Group the possibility of a Greater Manchester commissioned shared care protocol for monitoring of ESAs.” Source location 2019-0053-Responses
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish an operating procedure requiring direct GP communication and a provider response before confirming monitoring-dependent treatment plans.
Verbatim wording from the response “The actions being led by the Renal Team at Salford Royal Foundation Trust have been put in place a standard operating procedure to communicate directly with GP’s and ensure a response to any request for blood monitoring or any other service carried out locally. This will require a response from the local GP or provider before the treatment plan is confirmed. The Trust have confirmed that all correspondence with the patient will be copied to the GP. On a longer term implementation is the development of a shared care model – this has been described in a business case to Greater Manchester Medicines Management Group which will then go out to local commissioners.” Source location 2019-0053-Responses
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 Describe the shared-care model in a business case for consideration by the Greater Manchester Medicines Management Group and local commissioners.
Verbatim wording from the response “The actions being led by the Renal Team at Salford Royal Foundation Trust have been put in place a standard operating procedure to communicate directly with GP’s and ensure a response to any request for blood monitoring or any other service carried out locally. This will require a response from the local GP or provider before the treatment plan is confirmed. The Trust have confirmed that all correspondence with the patient will be copied to the GP. On a longer term implementation is the development of a shared care model – this has been described in a business case to Greater Manchester Medicines Management Group which will then go out to local commissioners.” Source location 2019-0053-Responses
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 Identify patients receiving or potentially requiring shared-care ESA pathways and write to GP practices to promote robust monitoring.
Verbatim wording from the response “Learning will be shared across the Northern Care Alliance (NCA) and communicated to Central Manchester Foundation Trust to ensure that shared care protocols are reviewed and that others can learn from the communication errors that occurred for Mr Mellor. Oldham CCG have been working” Source location 2019-0053-Responses
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 Notify the CCG that the Practice was asked to monitor a red-status medication and report the associated significant event.
Verbatim wording from the response “The Practice should have alerted the CCG to the fact that they were being asked to arrange monitoring of a red status medication so that the CCG could liaise with secondary care to arrange a Medication Management. We wrote to the CCG on 11 February 2019 to notify them of this significant event and the upcoming Coroner’s Inquest. Please find a copy of that letter enclosed with this response.” Source location 2019-0053-Responses
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 SPoA and District Nursing service followed due process and acted appropriately on the referral based on the information available.
Verbatim wording from the response “Both parties reviewed the information and timelines of events in regard to this referral to determine what collectively we would do differently if similar circumstances arose. It was determined that based on the information available the SPoA and District Nurses followed due process and acted accordingly. It was acknowledged at that time the practice did not have capacity to facilitate the full blood count although they were able to perform the blood pressure monitoring.” Source location 2019-0053-Responses
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 community nursing service was commissioned to provide phlebotomy only for housebound patients, and this patient was not housebound.
Verbatim wording from the response “The Oldham Adult Community Nursing service provides care for patients who are housebound, either permanently or temporarily, requiring treatment in their own home. There is also a Treatment Room service based in clinics across the borough for those patients’ not housebound but requiring District Nursing interventions. The service is commissioned to deliver a phlebotomy service to housebound patients only.” Source location 2019-0053-Responses
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 Practice should not accept responsibility for monitoring EPO; the CCG will liaise directly with the Trust and medicines management.
Verbatim wording from the response “During a telephone call with ████████ at the CCG on 29 March 2019, the Practice was informed that we should not agree to the monitoring of red category medications and should notify the CCG urgently if asked to do so. The CCG are liaising directly with the Trust and also with Medications Management regarding this issue. At the request of the Trust we have not written to the Trust and the CCG are liaising with them directly in relation to the issues identified by the Practice and by the CCG.” Source location 2019-0053-Responses
Open published response
9 May 2018 KIRSTY ELIZABETH TOLLEY · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Failure to carry out daily blood tests to monitor haemoglobin levels View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
×
AI-generated summary
KIRSTY ELIZABETH TOLLEY · 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
Kirsty Elizabeth Tolley had several health problems and was admitted to Queen Elizabeth Hospital with severe anaemia and a high temperature. She was later found unresponsive in bed on 19 November 2017 and was declared dead despite resuscitation. Concerns included blood tests not being carried out daily as required, incomplete Early Warning Score monitoring, and a lack of documented escalation or additional observations when scores reached 3; the medical cause of death was unascertained.
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 carry out daily blood tests to monitor haemoglobin levels
Wider context from the report “(1) Miss Tolley had a history of anaemia and had received a blood transfusion in 2016. On admission the Care Plan required blood tests to be taken daily to check haemoglobin levels. These were carried out on 10th, 13th, 14th and 16th (not daily) and showed decreasing levels. Ferinject was administered on 16th February. No blood tests to check haemoglobin levels were carried out after that date (except whilst in cardiac arrest). Blood tests were not carried out daily as required in the Care Plan , despite the requirement for monitoring, her history, the decreasing level of haemoglobin, and Ferinject being administered. There is no reason given in the Care Plan. Evidence was heard with regard to a Regulation 28 Report, that haemoglobin levels are not checked in the few days after Ferinject is administered as its effect is not seen straight away. This was not raised as a reason for not carrying out blood tests in evidence at the inquest. This was not recorded as a reason in the medical records.
Sadly, not only did this not give treating Doctors a picture of Miss Tolley's anaemia during her lifetime but has also meant there is a vacuum of evidence with regard to the medical cause of death.
” Source location KIRSTY ELIZABETH TOLLEY · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Medical plans may appropriately change without formally addressing each earlier entry unless there is a serious reason to question the initial opinion.
Verbatim wording from the response “Upon the patient’s admission the admitting consultant, ████████, wrote in his management plan that Kirsty was to have daily bloods. That plan clearly varied subsequently but his initial plan was based upon his clinical assessment at the time. I think it important to note that our admission document (Clerking Proforma) is not regarded as a rigid tool, perhaps as is seen with documentation like the Waterlow assessment or falls risk tools, for example. From the medical point of view the plan may, and should, change as different doctors subsequently review the patient and or the condition or working diagnoses change. In fact I would expect subsequent doctors visiting a patient always to have in mind an inquisitive and challenging approach to initial working diagnoses and management plans, and be prepared to alter them.” Source location 2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
Open published response
11 Jul 2014 Maria De Oliveria Alva LOPES · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Inadequate assessment of renal stone size and hydronephrosis View source
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Maria De Oliveria Alva LOPES · 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
Maria De Oliveria Alva LOPES died on 9 September 2012 after developing severe sepsis from an obstructing ureteric stone, followed by septic shock, multiorgan failure and rhabdomyolysis associated with propofol-related infusion syndrome. The principal concerns included delayed recognition and escalation of sepsis, delays in intensive care admission and treatment, inadequate supervision and control of propofol use, and insufficient monitoring for propofol-related complications.
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 Inadequate assessment of renal stone size and hydronephrosis
Wider context from the report “6. The assessment and size of the renal stone and hydronephrosis , and undue reliance on blood tests taken on admission (18 hours previously) to assess Mrs Lopes’s condition
” Source location Maria De Oliveria Alva LOPES · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.