16 Feb 2021 Mrs Ruby Baggaley · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Lack of clear escalation procedures and training for deteriorating postoperative patients View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Leeds Teaching Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Leeds Teaching Hospitals NHS Trust
Require the consultant anaesthetist to define postoperative care and NEWS thresholds for escalation to critical care outreach.
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Leeds Teaching Hospitals NHS Trust
Implement defined daytime and out-of-hours escalation using consultant contacts, NEWS2 and applicable deteriorating-patient and transfer policies.
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Leeds Teaching Hospitals NHS Trust
Develop a dedicated policy for deteriorating patients cared for at peripheral hospital sites.
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Leeds Teaching Hospitals NHS Trust
Establish a dedicated on-call consultant rota for Chapel Allerton Hospital.
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Leeds Teaching Hospitals NHS Trust
Provide rolling staff education and mandatory escalation-pathway and resuscitation training, recording junior doctors’ training on Electronic Staff Records.
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Mrs Ruby Baggaley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Ruby Baggaley, aged 90, sustained a right distal femur fracture in a fall and died in hospital on the night of 24 January 2020 after complex surgery. Her blood pressure remained abnormally low after surgery, but escalation to senior clinicians was delayed until she was critically ill. Concerns included inadequate monitoring and failure to escalate her deteriorating condition, as well as uncertainty about whether clear escalation instructions and additional staff training had been implemented.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear escalation procedures and training for deteriorating postoperative patients
Wider context from the report “In the period from 17:00 hours onwards her care was exclusively in the hands of a relatively junior doctor (CT2) and the nursing staff. No attempt was made to inform the surgeons or anaesthetist of the deterioration in her condition.
3) Between 16:00 hours and 20:45 hours Mrs Baggaley’s NEWS Score was 5 and remained at this level. No attempt was made to escalate her care to more senior clinicians.
It is not clear whether junior doctors and nursing staff now have clear instructions on when to escalate care in such circumstances, nor to whom.
4) By the time the surgeon was informed of the situation and travelled into the hospital around 22:00 hrs Mrs Baggaley’s condition had become critical.
It is not clear whether earlier intervention by senior clinicians would have avoided Mrs Baggaley suffering a cardiac arrest consequent upon her low blood pressure (as the Inquest was informed was the case). It is quite clear, however, that she was deprived of the opportunity to have a review by a senior clinician.
5) I am concerned that in the absence of precise information as to what, if any changes in escalation procedures have been implemented, or additional training provided to the staff involved, the potential for a comparable situation to occur again, remains.
” Source location Mrs Ruby Baggaley · Prevention of Future Deaths report
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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 Require the consultant anaesthetist to define postoperative care and NEWS thresholds for escalation to critical care outreach.
Verbatim wording from the response “On the day of surgery, the consultant anaesthetist will have the responsibility to clearly define the patient’s post-operative care, including NEWS scores that will require escalation to critical care outreach team for support out of hours.” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement defined daytime and out-of-hours escalation using consultant contacts, NEWS2 and applicable deteriorating-patient and transfer policies.
Verbatim wording from the response “During daytime working hours (08.00 -18.00) any concerns will be escalated to the consultant surgeon and anaesthetist responsible for the patient’s care. After 18.00 hours the escalation policy will be based upon clear objective assessments of the patient’s physiological status using the NEWS2 score and the Trust’s ‘Deteriorating Patient Policy’ and the ‘Transfer of Care Policy for Chapel Allerton Orthopaedic Centre’. A separate policy is being developed to specifically address the deteriorating patient being cared for in peripheral hospital sites. Plans are on-going to establish a dedicated on-call consultant rota for Chapel Allerton Hospital but in the meantime, the duty consultants at the LGI site will be available to provide advice and if necessary, review the patient.” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a dedicated policy for deteriorating patients cared for at peripheral hospital sites.
Verbatim wording from the response “During daytime working hours (08.00 -18.00) any concerns will be escalated to the consultant surgeon and anaesthetist responsible for the patient’s care. After 18.00 hours the escalation policy will be based upon clear objective assessments of the patient’s physiological status using the NEWS2 score and the Trust’s ‘Deteriorating Patient Policy’ and the ‘Transfer of Care Policy for Chapel Allerton Orthopaedic Centre’. A separate policy is being developed to specifically address the deteriorating patient being cared for in peripheral hospital sites. Plans are on-going to establish a dedicated on-call consultant rota for Chapel Allerton Hospital but in the meantime, the duty consultants at the LGI site will be available to provide advice and if necessary, review the patient.” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a dedicated on-call consultant rota for Chapel Allerton Hospital.
Verbatim wording from the response “During daytime working hours (08.00 -18.00) any concerns will be escalated to the consultant surgeon and anaesthetist responsible for the patient’s care. After 18.00 hours the escalation policy will be based upon clear objective assessments of the patient’s physiological status using the NEWS2 score and the Trust’s ‘Deteriorating Patient Policy’ and the ‘Transfer of Care Policy for Chapel Allerton Orthopaedic Centre’. A separate policy is being developed to specifically address the deteriorating patient being cared for in peripheral hospital sites. Plans are on-going to establish a dedicated on-call consultant rota for Chapel Allerton Hospital but in the meantime, the duty consultants at the LGI site will be available to provide advice and if necessary, review the patient.” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide rolling staff education and mandatory escalation-pathway and resuscitation training, recording junior doctors’ training on Electronic Staff Records.
Verbatim wording from the response “It is recognised that a rolling programme of staff education will be required to support the implementation of these planned changes. All staff in both the operating theatres and surgical wards will have regular training on escalation pathways and resuscitation. There will be compulsory mandatory training for the junior doctors starting their post at Chapel Allerton Hospital. This will be recorded on the Electronic Staff Records.” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
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3 Apr 2020 Edna May Davenport · Prevention of Future Deaths report Black Country
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Concerns raised 1
Delays in seeking medical review after head injury View source
This report raised 12 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.
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Edna May Davenport · 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
Edna May Davenport, a resident of Oak Court House residential care home, sustained head injuries during an unwitnessed assault by another resident and died in hospital on 12 December 2019. The report raised concerns about the removal of her alarm without documented alternative arrangements, inadequate recording and monitoring of observations, insufficient risk assessment of the other resident, and delays in responding to signs of head injury and deterioration.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in seeking medical review after head injury
Wider context from the report “(8) The deceased was an elderly lady who had suffered a head injury and was known to be anti-coagulant medication, yet no medical review was sought until an ambulance was called on 29/11/19 when the deceased became unresponsive . A concern was raised by hospital staff on her admission and a safe guarding referral was made.
” Source location Edna May Davenport · Prevention of Future Deaths report
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Concerns raised 1
Failure to escalate reported pain for further medical advice View source
This report raised 3 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
Charing Dale Limited
Share inquest learning and reinforce escalation, handover and related procedures through manager communications, team meetings and supervision.
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Terence Ewart JAMES · 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
Terence Ewart JAMES, aged 85, was living in a residential home when he sustained an unwitnessed fall on 17 April 2019 and a further fall on 20 April, resulting in a neck of femur fracture. He underwent surgery but became delirious, did not thrive, and died in hospital on 14 May 2019. Concerns included failures to inform the GP of the first fall, hand over the fall history to care staff, and escalate pain and deterioration for further medical advice.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to escalate reported pain for further medical advice
Wider context from the report “(3) A chiropodist raised concerns on 18th April that Mr James was in pain and this was not escalated for further medical advice .
” Source location Terence Ewart JAMES · Prevention of Future Deaths report
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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 Share inquest learning and reinforce escalation, handover and related procedures through manager communications, team meetings and supervision.
Verbatim wording from the response “A further staff meeting was held on Friday, 13 December 2019, and the manager shared the details of the inquest to ensure that all staff understood the importance of following the systems and protocols in place and to enforce expectations in this respect.” Source location 2019-0430-Response-from-Charing-Healthcare-Redacted-1
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The errors were considered individual judgment calls rather than evidence of systemic failures in existing processes.
Verbatim wording from the response “into the processes in place before the inquest, and we do believe that where errors occurred, they were individual judgment calls, rather than systemic errors.” Source location 2019-0430-Response-from-Charing-Healthcare-Redacted-1
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17 Dec 2019 Barry Jack Gordon Liffen · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Failure to seek clinical assessment when staff note deterioration in residents' health View source
This report raised 1 other concern. 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.
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Barry Jack Gordon Liffen · 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
Barry Jack Gordon Liffen, who had dementia and other chronic illnesses and was taking anticoagulants, fell at his sheltered accommodation on 10 March 2019 and sustained a head injury causing subdural bleeding. His condition later deteriorated, and he died in hospital on 11 May 2019 after developing recurrent pneumonia. The concerns identified were the need for clinical assessment after falls and when staff observe deterioration in frail residents at Glebelands.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to seek clinical assessment when staff note deterioration in residents' health
Wider context from the report “2. That clinical assessment be sought for persons at Glebelands whose health is noted to have deteriorated by staff .
” Source location Barry Jack Gordon Liffen · Prevention of Future Deaths report
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16 Dec 2019 Arnold Fletcher Ward · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to recognise and escalate significant pressure-ulcer deterioration promptly View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission NHS Greater Manchester Integrated Care Board Olea Care Ltd
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Olea Care Ltd
Provide wound-management refresher training to registered nurses and care staff.
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Olea Care Ltd
Embed React to Red wound-management training in induction for all new staff.
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Olea Care Ltd
Route tissue-viability referrals by email or telephone, confirm them by summary email and next-day calls, and track follow-up using diary and audit-sheet prompts.
View source
Olea Care Ltd
Notify the GP of all tissue-viability referrals and include wound management in weekly GP ward rounds.
View source
NHS Greater Manchester Integrated Care Board
Implement electronic pressure-ulcer photography at identification and regular intervals to monitor deterioration.
View source
NHS Greater Manchester Integrated Care Board
Change Tissue Viability referrals from fax to email and add prompts to follow up referrals not actioned within two working days.
View source
Care Quality Commission
Complete the extended comprehensive inspection of Fernlea Care Home, examining pressure-ulcer management and management oversight.
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Arnold Fletcher Ward · 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
Arnold Fletcher Ward was a resident at Fernlea Nursing Home who developed a deteriorating grade 4 sacral pressure ulcer, later associated with osteomyelitis, and died in hospital on 21 January 2019 from a myocardial infarction. Concerns included inadequate monitoring and escalation of the pressure ulcer, failure to follow up a referral to the Tissue Viability Nursing Team, and the resulting lack of appropriate wound dressing.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise and escalate significant pressure-ulcer deterioration promptly
Wider context from the report “The inquest heard that within the home the forms used did not capture the deterioration of the pressure ulcer or require detailed monitoring/use of photographs to track its progress. This meant that the significant and steep deterioration was not recognised and escalated at an early opportunity to the Tissue Viability Nursing team for expert wound management input. As a result the type of wound dressing he required were not utilised/available.
It had been captured in the notes that there had been a referral to the Tissue Viability Nursing team in October. There was no system in the home to chase up the team after a number of weeks had elapsed and there had been no response. The inquest heard that even in non-urgent cases the Tissue Viability Nursing team would contact a home requesting support in at least 10 days and more quickly in an urgent case.
” Source location Arnold Fletcher Ward · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide wound-management refresher training to registered nurses and care staff.
Verbatim wording from the response “Since the incident concerning AFW we have arranged for all our Registered Nurses to undertake third party wound management refresher training (either through a certified tissue viability course or the NHS “React to Red” training course). We have also extended this training to our care staff and to date 87% of the care team have undertaken the “React to Red” training recommended by the Local Authority. This training has now been implemented into our induction program for all new staff.” Source location 2019-0433-Response-from-Fernlea-Care-Home-Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed React to Red wound-management training in induction for all new staff.
Verbatim wording from the response “Since the incident concerning AFW we have arranged for all our Registered Nurses to undertake third party wound management refresher training (either through a certified tissue viability course or the NHS “React to Red” training course). We have also extended this training to our care staff and to date 87% of the care team have undertaken the “React to Red” training recommended by the Local Authority. This training has now been implemented into our induction program for all new staff.” Source location 2019-0433-Response-from-Fernlea-Care-Home-Redacted.pdf
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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 Route tissue-viability referrals by email or telephone, confirm them by summary email and next-day calls, and track follow-up using diary and audit-sheet prompts.
Verbatim wording from the response “During the time of the incident with AFW, the TVNs were in the process of transferring referrals from fax to email. They have acknowledged that there was a number of issues around that time with referrals and follow ups. We have since changed our processes to ensure all referrals to the TVNs are via e-mail or telephone followed up by a summary e-mail. All referrals are followed up by a phone call the day after irrespective of urgency status and prompts are placed in the diary and on a referral audit sheet for the care management team to follow up.” Source location 2019-0433-Response-from-Fernlea-Care-Home-Redacted.pdf
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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 Notify the GP of all tissue-viability referrals and include wound management in weekly GP ward rounds.
Verbatim wording from the response “After discussions with the GP it has been agreed that we will notify the GP of all referrals to the TVN and wound management will form part of the weekly GP ward-round.” Source location 2019-0433-Response-from-Fernlea-Care-Home-Redacted.pdf
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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 Implement electronic pressure-ulcer photography at identification and regular intervals to monitor deterioration.
Verbatim wording from the response “• Record Keeping Review in response to the issue that documentation in relation to the pressure ulcer failed to reflect the deterioration, and that photographs were not used to track the progress.” Source location 2019-0433-Response-from-Stockport-NHS-Redacted
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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 Change Tissue Viability referrals from fax to email and add prompts to follow up referrals not actioned within two working days.
Verbatim wording from the response “• Refresh of the requirements of the referral to Tissue Viability service process in response to the issues of the delay in escalation to the specialist Tissue Viability Nursing Team despite clear signs of deterioration, and No evidence of a robust system to track the status of a referral to the Tissue Viability Nursing Team” Source location 2019-0433-Response-from-Stockport-NHS-Redacted
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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 Complete the extended comprehensive inspection of Fernlea Care Home, examining pressure-ulcer management and management oversight.
Verbatim wording from the response “The matters of concerns which arose from the preventing future deaths report were reviewed by CQC and a decision was made to undertake an unannounced, focused inspection of the Fernlea Care Home. This was because the concerns indicated that the registered provider may have been/may still be in breach of the following fundamental standards:” Source location 2019-0433-Response-from-the-Care-Quality-Commission-Redacted
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26 Jun 2019 Mr Charles Knapp · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure to seek medical attention for patients’ pressure sores View source
This report raised 7 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.
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AI-generated summary
Mr Charles Knapp · 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
Mr Charles Knapp, who was paraplegic and dependent on care, developed necrotic pressure sores while living at home and later died in hospital on 24 February 2018 from aspiration pneumonia. The concerns included failures by Angel Solutions (UK) Ltd to maintain his hygiene, reposition him, seek medical attention, provide two carers as required, and maintain or supply complete care records; the Coroner was concerned that inadequate care and records could put other service users at risk of future deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to seek medical attention for patients’ pressure sores
Wider context from the report “(i) Angel Solutions (UK) Ltd omitted to maintain Mr Knapp’s personal hygiene or regularly reposition him, and thereafter omitted to seek medical attention for the pressure sores . These omissions contributed to the development of the pressure sores and to Mr Knapp’s death.
” Source location Mr Charles Knapp · Prevention of Future Deaths report
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19 Jun 2019 James William Francis · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Delays in seeking out-of-hours medical advice and requesting GP review View source
This report raised 13 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
Shaw Healthcare Limited
Implement the GP and NHS 111 escalation procedure, including urgency assessment, clear clinical communications and service-level auditing.
View source
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in seeking out-of-hours medical advice and requesting GP review
Wider context from the report “I heard evidence that when Mr Francis was sick three times during the late afternoon and early evening of the day of his fall, no action was taken to seek out of hours medical advice
In addition, despite a significant deterioration in Mr Francis condition later in the day of his fall and more significantly the following morning and after five separate referrals by the day support worker to the team leader, there was a five hour delay in making a simple telephone call to request a GP visit . Further, there does not appear to have been any thought given to making a call to NHS 111 for advice. It was also unclear exactly what information was given to the GP surgery to stress the history and deterioration in Mr Francis condition
” Source location James William Francis · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the GP and NHS 111 escalation procedure, including urgency assessment, clear clinical communications and service-level auditing.
Verbatim wording from the response “I also refer to the attached “Request for attendance of GP” policy which states that if a Service User develops a health problem or if the Service User requests to see their GP, the senior person on duty will assess the situation and contact the surgery, before the medication round commences. In assessing the urgency of the situation, the GP Surgery can be approached for advice or otherwise to liaise with the District Nursing service as appropriate it goes on to set very clear expectations in referring to the NHS 111 service and also the importance of clear communications.” Source location 2019-0202-Response-by-Shaw-Healthcare
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22 May 2019 Jonathan Richard McCARTHY · Prevention of Future Deaths report North West Kent
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Concerns raised 1
Failure to escalate to the medical team View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Maidstone and Tunbridge Wells NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Maidstone and Tunbridge Wells NHS Trust
Implement the approved blood-glucose monitoring guideline, including traffic-light interpretation, hypoglycaemia management and escalation procedures.
View source
Maidstone and Tunbridge Wells NHS Trust
Provide monthly induction training for clinical support workers, registered nurses and junior doctors on diabetic monitoring, equipment, escalation and referrals.
View source
Maidstone and Tunbridge Wells NHS Trust
Deliver targeted staff training and share case learning on testing, abnormal-result response and escalation to medical or diabetes teams.
View source
Maidstone and Tunbridge Wells NHS Trust
Develop and introduce connected blood-glucose and ketone meters with real-time dashboard escalation, replacing existing meters and training staff.
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AI-generated summary
Jonathan Richard McCARTHY · 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
Jonathan Richard McCarthy was admitted to hospital with confusion, aspiration pneumonia, sepsis, acute kidney injury and swallowing difficulties, and later deteriorated with another aspiration pneumonia and hyperglycaemia. The stated concerns were failures to correctly monitor blood sugar and ketones, administer the correct insulin dose, and provide adequate nursing care and escalation to the medical team.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to escalate to the medical team
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The Trust failed to correctly monitor the blood sugar and ketone testing of Jonathan Richard
McCarthy
(2) The Trust failed to administer the correct does of insulin
(3) There was inadequate nursing care and a failure to escalate to the medical team when it was clear
this should be carried out.
” Source location Jonathan Richard McCARTHY · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the approved blood-glucose monitoring guideline, including traffic-light interpretation, hypoglycaemia management and escalation procedures.
Verbatim wording from the response “It was identified during the Serious Incident investigation that the staff concerned were unsure of the appropriate procedures relating to the monitoring of blood sugar and ketone testing therefore a Trust Guideline for capillary blood glucose monitoring for inpatients and day cases with Diabetes Mellitus over the age of 16 years has been written and approved by the Medical Specialities Directorate. This guideline is in keeping with the standard set by the National Inpatient Diabetes Audit. The guideline has been out for wide consultation with comments from clinicians across the trust being received. Contained within the Guideline is a coloured “traffic light” risk tool to assist staff on the wards to interpret the results of blood sugar and ketone testing, with recommended actions to undertake and escalation as appropriate.” Source location 2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide monthly induction training for clinical support workers, registered nurses and junior doctors on diabetic monitoring, equipment, escalation and referrals.
Verbatim wording from the response “Ongoing monthly training has been in place for new Clinical Support Workers and Registered Nurses and this is undertaken during their first weeks on induction to the trust where diabetic management is highlighted in bite-sized sessions. This is delivered by the Diabetes Specialist Nurses on both sites. This demonstrates the use of equipment (by the Point of Care Team), the new algorithm for the recognition and management of hyper- and hypo-glycaemia and how to request in-patient referrals to the Diabetes Team and escalate for medical attention. The Blood Glucose Guideline also forms part of the Junior doctors induction programme which is also undertaken by the Diabetes Team.” Source location 2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver targeted staff training and share case learning on testing, abnormal-result response and escalation to medical or diabetes teams.
Verbatim wording from the response “As outlined in response to question (1), this aspect of Mr McCarthy’s care has been addressed directly with the staff concerned on those on the ward with specific training and the learning from Mr McCarthy’s case has been shared. The introduction of the algorithm, the raised awareness of the importance of testing and acting/escalating abnormal results have been outlined and incorporated into the new guidance. This includes the element of how and when to escalate to medical teams or diabetic nurse specialists for assistance and review.” Source location 2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
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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 introduce connected blood-glucose and ketone meters with real-time dashboard escalation, replacing existing meters and training staff.
Verbatim wording from the response “The Trust has also been out to tender for a blood glucose and ketone testing meter that has the capability of linking into the existing clinical observation monitoring tool (Nervecentre) which would record and escalate results accordingly. In addition blood ketone testing machines have been purchased and assigned to key locations in the trust with the aim to ultimately have them on each ward. The Emergency Departments on both sites have these in place and appropriate training has been rolled out to the nursing staff. In addition the Diabetic Nurse Specialists also carry ketone testing machines to support access and training to the ward staff as and when required.” Source location 2019-0179-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust_Redacted
Open published response
2 May 2019 Mr Royston Kemp · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to escalate to medical care or refer 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.
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AI-generated summary
Mr Royston Kemp · 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
Mr Royston Kemp, an 85-year-old care home resident with dementia and a history of fractures and falls, suffered an unwitnessed traumatic fracture of his left femur in February 2016. He was not referred to hospital until two days after signs of injury and died on 20 March 2016 from pneumonia, aspiration and advanced dementia, with the fracture-related immobility identified as a key contributor. Concerns included failure by a nurse to act on leg swelling and temperature differences, establish the care assistant’s concerns, measure vital signs, or escalate for medical assessment and referral.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to escalate to medical care or refer
Wider context from the report “A nurse working at Marlborough Court Care Home, who has already been referred to the NMC assessed this frail elderly resident whose leg caused concern to care assistants. In doing so her evidence concerned the coroner was:
1) She found one leg more swollen than the other and of a different temperature
but took no action
2) She failed to establish the care assistant’s concern or whether she had met the
concern before or after her assessment
3) She failed to measure Vital Signs
4) She failed to escalate to medical care or refer , in the process failed to enable a
diagnosis of fractured femur to be made.
” Source location Mr Royston Kemp · Prevention of Future Deaths report
Open source report
8 Aug 2018 Dr Donald Clegg · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Delays in seeking medical attention when service users deteriorate View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Dr Donald Clegg · 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
Dr Donald Clegg, who had complex physical and mental health needs, was transferred to a short-term residential placement that was unable to manage his care needs. Concerns included inadequate assessment and communication during the transfer, unsafe medication management, insufficient monitoring, delayed recognition of deterioration and inadequate record keeping. He developed breathing difficulties and seizure-like activity on 26 February 2018, was admitted to hospital and died later that day; the stated cause of death was acute left ventricular heart failure due to severe ischaemic heart disease and left ventricular hypertrophy.
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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 Delays in seeking medical attention when service users deteriorate
Wider context from the report “4. Staff were unable to recognise the deteriorating adult and did not seek medical attention in a timely manner when signs of change became apparent . This potentially puts service users at risk of harm/death.
” Source location Dr Donald Clegg · Prevention of Future Deaths report
Open source report
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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 Review and develop training to help staff recognise deterioration, question medical professionals, and identify triggers for seeking further advice.
Verbatim wording from the response “4. Staff were unable to recognise the signs of deterioration and did not seek medical attention in a timely manner
This finding is one which we have reflected on at some length. As you will be aware, Elmhurst does not hold a Nursing registration and the staff we employ are social care staff and not medically qualified. Therefore the monitoring that we undertake when someone is unwell needs to be appropriate to the specifics of our registration. Having reflected and reviewed our approach I believe that this service would benefit from additional training and we also need to empower staff to ask more and better questions of medical professionals in order to understand what to expect, and what triggers to look for in an individual’s specific case in order to know when to seek further advice or involve medical professionals.” Source location 2018-0269-Response-by-Persona
Open published response
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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 Monitoring of unwell service users is limited to what is appropriate for Elmhurst’s social-care registration and staff’s non-medical qualifications.
Verbatim wording from the response “4. Staff were unable to recognise the signs of deterioration and did not seek medical attention in a timely manner
This finding is one which we have reflected on at some length. As you will be aware, Elmhurst does not hold a Nursing registration and the staff we employ are social care staff and not medically qualified. Therefore the monitoring that we undertake when someone is unwell needs to be appropriate to the specifics of our registration. Having reflected and reviewed our approach I believe that this service would benefit from additional training and we also need to empower staff to ask more and better questions of medical professionals in order to understand what to expect, and what triggers to look for in an individual’s specific case in order to know when to seek further advice or involve medical professionals.” Source location 2018-0269-Response-by-Persona
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.