Recurring concern

Delays in progressing time-critical surgical treatment

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First reported 4 Dec 2013•Latest report 5 Jun 2025

Definition

What this concern includes

Includes delays or unreliable progression at any dedicated point in the surgical treatment pathway, including readiness assessment, prioritisation, theatre access, reassessment, referral or transfer, where the reports support that the treatment should have proceeded within a clinically important timeframe.

Not included

  • Excludes delays in non-surgical treatment or general healthcare referrals that are not part of a surgical treatment pathway.
  • Excludes generic staffing, capacity, communication or documentation deficiencies unless they are specifically tied to delayed progression of surgical treatment.
  • Excludes failures concerning the safety or quality of surgery after it has commenced, rather than timely progression to surgery.
Reports
13

Distinct published reports

Individual concerns
14

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
27

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Surrey and Sussex Healthcare NHS Trust3
NHS England2
Barts Health NHS Trust1
Blackpool Teaching Hospitals NHS Foundation Trust1
Calderdale Royal Hospital1
Department of Health and Social Care1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
East Kent Hospitals University NHS Foundation Trust1
Greater Manchester Health and Social Care Partnership1
Mid and South Essex NHS Foundation Trust1
North Cumbria Integrated Care NHS Foundation Trust1
Royal Sussex County Hospital1
Tameside and Glossop Integrated Care NHS Foundation Trust1
University Hospitals Sussex NHS Foundation Trust1

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.

  1. Blackpool and the Fylde

    AI-generated summary

    Thomas William OLDCORN · 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 William Oldcorn was admitted with cardiac symptoms, diagnosed with a non-ST elevation myocardial infarction, and later found to have severe left main stem coronary artery disease. He died of a cardiac arrest while awaiting cardiac MRI and coronary artery bypass surgery. The report raised concern that surgery waiting times exceeded the national seven-day target and that inadequate resources prevented the target from being met; it stated that the inability to perform surgery within the target contributed to his death.

    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 surgery beyond 7 days from angiography

    Wider context from the report

    “(1) I heard evidence during the course of Mr Oldcorn's inquest that despite National targets of 7 days from angiography to surgery at the time of his death the waiting time for surgery was 14 days, that it has since risen to 17 days and that there are inadequate resources to meet the national target. ”

    Source location

    Thomas William OLDCORN · 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

    Recruit and appoint a Consultant Surgeon to strengthen cardiothoracic service capacity.

    Verbatim wording from the response

    “Whilst the service is planned to run on 50 weeks of the year, the job plans of both the Consultant Anaesthetists and Surgeons are based on 42 weeks so both flexible job sessions and cross cover are utilised in order to maintain the activity against plan. The Trust has recruited a Consultant Surgeon who commenced in post on 7th July 2025, and a Consultant Anaesthetist who is due to commence in post on 25th August 2025. Consultant annual leave policies at sub-speciality levels have been aligned to reduce the impact seen from lack of surgeon availability. In addition, the staffing levels across Theatres and Cardiac Intensive care have been authorised to recruit to the workforce gaps previously seen.”

    Source location

    Response from Blackpool Teaching Hospital NHS Foundation Trust
    Page 2 · response
    Published 18 June 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Recruit and appoint a Consultant Anaesthetist to strengthen cardiothoracic service capacity.

    Verbatim wording from the response

    “Whilst the service is planned to run on 50 weeks of the year, the job plans of both the Consultant Anaesthetists and Surgeons are based on 42 weeks so both flexible job sessions and cross cover are utilised in order to maintain the activity against plan. The Trust has recruited a Consultant Surgeon who commenced in post on 7th July 2025, and a Consultant Anaesthetist who is due to commence in post on 25th August 2025. Consultant annual leave policies at sub-speciality levels have been aligned to reduce the impact seen from lack of surgeon availability. In addition, the staffing levels across Theatres and Cardiac Intensive care have been authorised to recruit to the workforce gaps previously seen.”

    Source location

    Response from Blackpool Teaching Hospital NHS Foundation Trust
    Page 2 · response
    Published 18 June 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Align subspecialty consultant annual-leave policies to reduce surgeon-availability gaps.

    Verbatim wording from the response

    “Whilst the service is planned to run on 50 weeks of the year, the job plans of both the Consultant Anaesthetists and Surgeons are based on 42 weeks so both flexible job sessions and cross cover are utilised in order to maintain the activity against plan. The Trust has recruited a Consultant Surgeon who commenced in post on 7th July 2025, and a Consultant Anaesthetist who is due to commence in post on 25th August 2025. Consultant annual leave policies at sub-speciality levels have been aligned to reduce the impact seen from lack of surgeon availability. In addition, the staffing levels across Theatres and Cardiac Intensive care have been authorised to recruit to the workforce gaps previously seen.”

    Source location

    Response from Blackpool Teaching Hospital NHS Foundation Trust
    Page 2 · response
    Published 18 June 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Authorize recruitment to address identified Theatre and Cardiac Intensive Care workforce gaps.

    Verbatim wording from the response

    “Whilst the service is planned to run on 50 weeks of the year, the job plans of both the Consultant Anaesthetists and Surgeons are based on 42 weeks so both flexible job sessions and cross cover are utilised in order to maintain the activity against plan. The Trust has recruited a Consultant Surgeon who commenced in post on 7th July 2025, and a Consultant Anaesthetist who is due to commence in post on 25th August 2025. Consultant annual leave policies at sub-speciality levels have been aligned to reduce the impact seen from lack of surgeon availability. In addition, the staffing levels across Theatres and Cardiac Intensive care have been authorised to recruit to the workforce gaps previously seen.”

    Source location

    Response from Blackpool Teaching Hospital NHS Foundation Trust
    Page 2 · response
    Published 18 June 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Use a dashboard, dedicated coordinator and consultant-led RAG review to monitor urgent CABG patients and identify delays.

    Verbatim wording from the response

    “A dashboard is in place to track all patients awaiting urgent CABG surgery, enabling proactive management and early identification of any potential delays. We have a dedicated nursing co-ordinator for inpatients who works closely with our dedicated Cardiothoracic Consultant Surgeon in-patient lead to regularly review each patient, monitoring their clinical priority and establishing a collective clinical overview. This review is captured on a RAG-rated system, with red/critical patients being given higher priority.”

    Source location

    Response from Blackpool Teaching Hospital NHS Foundation Trust
    Page 2 · response
    Published 18 June 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and ratify an escalation policy for daily senior-clinician review and prioritisation before patients reach the seven-day threshold.

    Verbatim wording from the response

    “The above immediate action, implemented as a test of change, will now be formalised with the development of an escalation policy to ensure that any patient approaching the 7-day threshold is reviewed daily by a senior clinician and prioritised accordingly. The Trust will have the policy completed and ratified by September 2025.”

    Source location

    Response from Blackpool Teaching Hospital NHS Foundation Trust
    Page 2 · response
    Published 18 June 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish quality-improvement methodology to oversee compliance with national urgent cardiac-surgery targets.

    Verbatim wording from the response

    “Quality improvement methodology has been established to oversee compliance with national targets for urgent cardiac surgery.”

    Source location

    Response from Blackpool Teaching Hospital NHS Foundation Trust
    Page 3 · response
    Published 18 June 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct monthly audits, monitor incidents and harms, and report findings through Trust governance committees to adjust provision.

    Verbatim wording from the response

    “Monthly audits are being conducted and monitoring of incidents and harms, with findings reported to the Trust Risk Committee, Clinical Governance Committee and Performance meetings with appropriate adjustments to the provision made.”

    Source location

    Response from Blackpool Teaching Hospital NHS Foundation Trust
    Page 3 · response
    Published 18 June 2025

    Open published response

  2. Nottinghamshire

    AI-generated summary

    Mrs Marina May Raisbeck · 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 Marina May Raisbeck died on 7 November 2023 at Doncaster Royal Infirmary from sepsis secondary to a perianal abscess. The report identifies concerns about the lack of systems to prioritise urgent surgical patients awaiting transfer and to monitor their clinical parameters at Bassetlaw District General 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

    Lack of a system for prioritisation of urgent surgical patients awaiting transfer

    Wider context from the report

    “1. The lack of a system for prioritisation of urgent surgical patients awaiting transfer to DRI from the Emergency Department at Bassetlaw District General Hospital ”

    Source location

    Mrs Marina May Raisbeck · 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

    Conduct daily face-to-face clinical assessments of surgical patients awaiting transfer to prioritise transfers and monitor blood tests.

    Verbatim wording from the response

    “To enhance this standard, the Trust has immediately implemented a new initiative in Bassetlaw Hospital whereby every morning a Surgical Advanced Clinical Practitioner will undertake a face to face assessment of all surgical patients awaiting transfer to Doncaster Royal Infirmary in order to prioritise transfer. This assessment will include a full clinical review including monitoring blood tests.”

    Source location

    Response from Doncaster and Bassetlaw Teaching Hospitals
    Page 1 · response
    Published 19 May 2025

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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 and roll out a digital tracking system monitoring referred patients’ physiology, sepsis parameters and observations for clinical-team oversight and prioritisation.

    Verbatim wording from the response

    “The Trust has successfully developed a tracking system which provides oversight to the host and receiving clinical teams and monitors the patient’s physiology parameters (including sepsis) and observations. It also enables clinical teams to prioritise patient care. This digital programme of work has already been rolled out in Acute Medicine and Paediatrics on both Bassetlaw and Doncaster Hospital sites to allow them to easily view all patients in the ED that have been referred to them.”

    Source location

    Response from Doncaster and Bassetlaw Teaching Hospitals
    Page 2 · response
    Published 19 May 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Tailor the tracking system to orthopaedic standards and complete its implementation.

    Verbatim wording from the response

    “Discussions are nearing completion with our orthopaedic team to tailor the tracking system to reflect their standards of care and implementation is expected to be complete within 3-6 months.”

    Source location

    Response from Doncaster and Bassetlaw Teaching Hospitals
    Page 2 · response
    Published 19 May 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Discuss implementation of the tracking system with wider specialties for surgical patients.

    Verbatim wording from the response

    “Meanwhile, further discussions with our wider specialties are commencing to implement the tracker for our surgical patients.”

    Source location

    Response from Doncaster and Bassetlaw Teaching Hospitals
    Page 2 · response
    Published 19 May 2025

    Open published response

  3. Essex

    AI-generated summary

    William Charles Hare (Bill) · Prevention of Future Deaths report

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

    Report summary

    William Charles Hare (Bill) presented with abdominal and left loin pain in November 2022 and was subsequently diagnosed with metastatic urothelial cancer. He died in a hospice on 23 January 2024 after delays in diagnosis and treatment, including delays in biopsy, specialist review, MDT consideration, hospital transfer and scan results. The report identified systemic and procedural errors and ineffective coordination between Basildon and Southend Hospitals as substantive concerns.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in progressing treatment while patients remain eligible for surgery

    Wider context from the report

    “v. A further delay occurred from 4 September, as Bill had been assessed as unfit for surgery due to his HBA1c reading. Whilst this is unlikely to have been relevant by the cancer, there was likely to have been an opportunity, had his case been progressed earlier, at which his HBA1c was at an acceptable level for the procedure to be carried out. ”

    Source location

    William Charles Hare (Bill) · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide consultant-led pre-operative support, including early identification, specialist review, endocrinology support and monitoring for patients with poorly controlled HBA1c.

    Verbatim wording from the response

    “We have improved the quality of care delivered at our pre-assessment clinics. Specialist staff are now reviewing clinic lists for patients such as Mr Hare, where HBA1c is poorly controlled and would benefit from early support from the hospital. We know that hospital led support yields the best outcomes for these patients, and so we have increased clinical capacity in this area. In doing so we monitor any deterioration of HBA1c control and work closely with our patients to counsel them on the impact this may have on the future treatments we can offer.”

    Source location

    Response from Mid and South Essex NHS Foundation Trust
    Page 2 · response
    Published 6 January 2025

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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

    Use one comprehensive patient-tracking system across hospital sites to monitor cancer pathways, diagnostic reporting, timescales and required escalations.

    Verbatim wording from the response

    “We now have one comprehensive patient tracking system for all hospital sites providing a centralised monitoring for all cancer patients and their progress through the cancer pathway.”

    Source location

    Response from Mid and South Essex NHS Foundation Trust
    Page 2 · response
    Published 6 January 2025

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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

    Earlier progression would not establish that surgery was feasible because HbA1c was never optimal and surgical complication risks remained high.

    Verbatim wording from the response

    “My colleagues advise me that Mr Hare’s HBA1c control was unfortunately in decline since his first presentation at the preassessment clinic on 4th September 2023. We cannot speculate that Mr Hare would have been a suitable candidate for the procedure at an earlier date as his HBA1c was never optimal for surgery and he was at high risk of complications including stroke. Poorly controlled HBA1c places patients at risk of death from such procedures and these risks were explained to Mr Hare when the clinical decision was that he was at too high a risk for surgery at that time. He was referred to his GP for HBA1c optimisation.”

    Source location

    Response from Mid and South Essex NHS Foundation Trust
    Page 3 · response
    Published 6 January 2025

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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

    By 5 January, disease progression had made the condition inoperable, so surgery would not have been appropriate treatment.

    Verbatim wording from the response

    “On review of Mr Hare’s MRI scan taken on 5th January 2024 and his clinical presentation at that time, regrettably the disease progression had made his condition inoperable, and surgery would not have been the appropriate treatment.”

    Source location

    Response from Mid and South Essex NHS Foundation Trust
    Page 3 · response
    Published 6 January 2025

    Open published response

  4. Surrey

    AI-generated summary

    Anne Johnston Rowland · 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

    Anne Johnston Rowland suffered a neck of femur fracture on 27 February 2023 and underwent fixation surgery on 3 March 2023 after waiting for surgery at East Surrey Hospital. Her immobility while waiting contributed to aspiration pneumonia, and she died at the hospital on 31 March 2023. The coroner was concerned that limited theatre capacity, infrastructure risks, and the Trust’s 48-hour surgery metric could delay hip fracture surgery beyond the NICE timeframe and place patients at risk of early death.

    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

    Outstanding infrastructure repairs affecting timely hip-fracture surgery

    Wider context from the report

    “Continuing infrastructure risks at East Surrey Hospital have potential to compromise the Trust’s ability to perform operations on patients with fractured hips on the day of admission or the day thereafter, which is the timeframe set out in the NICE Guidelines on the Management of Hip Fractures. East Surrey Hospital use a metric of 48 hours within which to conduct such surgery and not the NICE timeframe for hip surgery. Early mobilisation is recommended for hip fracture patients to reduce the risk of complications, including pneumonia. The coroner is concerned that in using a different metric to that in the NICE guidelines and the outstanding infrastructure repairs the Trust is placing such patients at risk of early death. ”

    Source location

    Anne Johnston Rowland · 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

    Approve multimillion-pound investment in new theatre-complex air-handling and chiller systems.

    Verbatim wording from the response

    “6. The Trust's Executive Committee have approved the case for a”

    Source location

    Response from Surrey and Sussex Healthcare
    Page 2 · response
    Published 21 March 2024

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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

    Install new chillers and air-handling units for half of the theatre complex as the first phase of infrastructure improvements.

    Verbatim wording from the response

    “multimillion-pound investment in 2023-24 for new air handling and chillers for the theatre complex which will correct the long-term problems experienced in the orthopaedic theatres and will prevent the cancellation of lists due to infrastructure failings. The first phase of this work was completed in April 2024, with new chillers and air handling units installed for half of the theatre complex. The second phase requires more substantial capital work but will be completed by the end of 2024, with new chillers and air handling units installed for the other half of the theatre complex.”

    Source location

    Response from Surrey and Sussex Healthcare
    Page 3 · response
    Published 21 March 2024

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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 second phase of theatre-complex infrastructure work by installing new chillers and air-handling units for the remaining half.

    Verbatim wording from the response

    “multimillion-pound investment in 2023-24 for new air handling and chillers for the theatre complex which will correct the long-term problems experienced in the orthopaedic theatres and will prevent the cancellation of lists due to infrastructure failings. The first phase of this work was completed in April 2024, with new chillers and air handling units installed for half of the theatre complex. The second phase requires more substantial capital work but will be completed by the end of 2024, with new chillers and air handling units installed for the other half of the theatre complex.”

    Source location

    Response from Surrey and Sussex Healthcare
    Page 3 · response
    Published 21 March 2024

    Open published response

  5. Surrey

    AI-generated summary

    Bavaniamma Theiventhiran · 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

    Bavaniamma Theiventhiran, aged 80, fractured her left neck of femur in a fall at home on 26 February 2023 and was admitted to East Surrey Hospital. Although there was no clinical reason to delay surgery, it took place on 2 March 2023, and she died at the hospital on 6 March 2023 after developing acute kidney injury. The Coroner was concerned that East Surrey Hospital was not meeting recommended surgery timeframes for over half of patients with fractured neck of femur, placing such patients at risk of early death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide hip surgery within the recommended timeframe for patients with fractured neck of femur

    Wider context from the report

    “The NICE Guideline on the Management of Hip Fractures recommends that hip surgery take place on the day of the injury or the day thereafter in order, amongst other things, to reduce complications. The most recent monthly figures indicate that East Surrey Hospital is not meeting this timeframe for over half of patients who present to the hospital with a fractured neck of femur. The Coroner is concerned that in failing to comply with the NICE Guideline in this way, the Trust is placing such patients at risk of early death. ”

    Source location

    Bavaniamma Theiventhiran · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. Surrey

    AI-generated summary

    Douglas Nickols · 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

    Douglas Nickols suffered an unwitnessed fall at his care home on 28 February 2023, sustaining a fractured left neck of femur. He was admitted to East Surrey Hospital, but surgery did not take place until 5 March 2023; he later developed bronchopneumonia and died at the hospital on 11 March 2023. The principal concern was that limited trauma capacity meant hip-fracture surgery could be delayed beyond the NICE-recommended timeframe, potentially placing patients at risk of early death.

    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 performing operations for hip fracture patients within the day of admission or the following day

    Wider context from the report

    “On some occasions at East Surrey Hospital it is not possible to perform operations on patients with fractured hips on the day of admission or the day thereafter, which is the timeframe set out in the NICE Guidelines on the Management of Hip Fractures. Early mobilisation is recommended for hip fracture patients to reduce the risk of complications, including pneumonia. The Coroner is concerned that in failing to comply with the NICE guidelines in this way, the Trust is placing such patients at risk of early death. ”

    Source location

    Douglas Nickols · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. East London

    AI-generated summary

    Christine Goodfriday Nakaefeero · 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

    Christine Goodfriday Nakaefeero was found unresponsive at home on 21 June 2022 and died from a pulmonary embolism caused by a deep vein thrombosis. The report raises concerns that recommended hysterectomy surgery for her uterine fibroids was not arranged, and that the VTE assessment did not account for her large fibroids and use of tranexamic acid.

    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 maintain patients within the gynaeology care pathway and ensure timely surgery

    Wider context from the report

    “1. Ms Nakaefeero was assessed at a Gynae-oncology clinic in early 2019. The patient was diagnosed as not suffering from any form of cancer and was therefore referred on to the “benign” gynaeology team. Ms Nakaefeero was advised that it was likely that the most effective treatment for her condition was a hysterectomy. It was expected that the likely wait for this treatment would be 6 months. Ms Nakaefeero was not allocated an appointment and therefore had not received the necessary surgery by the time of her death in June 2022. Had the surgery been undertaken it is probable that she would not have developed a pulmonary embolism. Although the trust has investigated these circumstances and implemented change, no clear explanation could be offered for why the deceased slipped out of this care pathway. I am not satisfied that the risk of re-occurrence has been properly addressed. ”

    Source location

    Christine Goodfriday Nakaefeero · 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

    Implement a fully electronic outpatient outcome system to record clinic outcomes in real time and maintain an auditable patient pathway trail.

    Verbatim wording from the response

    “We are implementing a fully electronic outpatient outcome system using outpatient organiser on our Cerner millennium system. This provides real time outcoming within clinics, and an electronic audit trail to track the patient along the pathway. Alongside the use of electronic outcome forms, the Trust is rolling out LUNA, a digital monitoring tool for patient tracking lists which will replace our current electronic waiting list tool at the end of September 2023. LUNA has the ability to pick up errors allowing staff to make corrections. It has an AI tool that reviews letters for key text which can indicate where incorrect discharge is matched with a letter stating the patient should be seen again. Therefore, this can be corrected, and a follow up appointment sent to the patient .”

    Source location

    Response from Barts Health NHS Trust
    Page 1 · response
    Published 28 July 2023

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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

    Roll out LUNA as the patient tracking-list tool, replacing the existing electronic waiting-list system and identifying errors requiring correction or follow-up.

    Verbatim wording from the response

    “We are implementing a fully electronic outpatient outcome system using outpatient organiser on our Cerner millennium system. This provides real time outcoming within clinics, and an electronic audit trail to track the patient along the pathway. Alongside the use of electronic outcome forms, the Trust is rolling out LUNA, a digital monitoring tool for patient tracking lists which will replace our current electronic waiting list tool at the end of September 2023. LUNA has the ability to pick up errors allowing staff to make corrections. It has an AI tool that reviews letters for key text which can indicate where incorrect discharge is matched with a letter stating the patient should be seen again. Therefore, this can be corrected, and a follow up appointment sent to the patient .”

    Source location

    Response from Barts Health NHS Trust
    Page 1 · response
    Published 28 July 2023

    Open published response

  8. Manchester South

    AI-generated summary

    Maureen Harrop · 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

    Maureen Harrop, a care home resident, suffered an accidental fall resulting in a fracture to the neck of her femur. She experienced prolonged waits in the Emergency Department and for surgery, which was delayed because of limited bed and theatre capacity. She later developed a urinary tract infection, deteriorated, and died from urosepsis; the report raised concerns about the impact of these delays on her condition.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide surgery within 36 hours

    Wider context from the report

    “2. The evidence at the Inquest was that the NICE guidance promotes surgery within 36 hours. In Mrs Harrop’s case that was not achieved due to a lack of theatre capacity. The impact of the delay on her overall physiological reserves was significant ”

    Source location

    Maureen Harrop · 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

    Operate daily trauma and surgical bed-planning processes to identify patients awaiting hip-fracture surgery, agree care plans, and track waiting times and required pre-operative tests.

    Verbatim wording from the response

    “The trauma and orthopaedic department run a daily trauma meeting, where all patients with hip fractures who are awaiting surgery are identified. Individual plans of care and management are agreed clinically with the on-call orthopaedic consultant and trauma coordination team. An overview of these patients is also provided to the surgical bed meeting each morning, including the status of each patient and the current wait time for surgery.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 5 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Schedule clinically suitable hip-fracture patients for surgery within 36 hours and escalate unavailable theatre capacity through urgent trauma and elective-list review and divisional approval.

    Verbatim wording from the response

    “In response to your second concern, the Trust recognises that best practice and NICE guidance states that patients that have sustained a hip fracture should have timely surgery to repair the injury within 36 hours of admission, where the patient is clinically stable to undergo surgery - Overview | Hip fracture: management | Guidance | NICE. To manage these patients within the appropriate timeframe alongside competing priorities within the trauma and elective services, the Division of Surgery, Women’s and Children’s services (SWC) have reviewed and strengthened their processes.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 5 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Report surgery delays, complete root-cause analyses, review findings weekly, and monitor compliance through internal returns.

    Verbatim wording from the response

    “Where the Trust is not able to meet the 36 hour timeframe for surgery for a patient with a hip fracture, a clinical incident report is submitted. Following the incident, a root cause analysis (RCA) is completed by the trauma coordinators to identify the reasons for the delay and opportunities for learning. The RCA investigations are reviewed weekly in the “Neck Of Femur (NOF) Review Meeting” for comment, action and approval. This meeting is attended by the Clinical Lead for Neck of Femur, the Matron for Trauma and Orthopaedics and the Directorate Manager. Compliance is monitored through regular internal returns.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 5 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Submit daily hip-fracture data to the National Hip Fracture Database to support quality improvement and guideline-aligned care.

    Verbatim wording from the response

    “The Trust also submits data to the National Hip Fracture Database, which specifically looks at care for patients over the age of 60, who undergo surgery following a hip fracture. This includes data to improve care through quality improvement, in line with NICE guidelines and the National Falls and Fragility Fracture Audit Programme (FFFAP). Data is submitted by the trauma coordinators daily.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 5 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement and monitor a divisional fractured-neck-of-femur improvement programme through senior leadership and quality-governance oversight.

    Verbatim wording from the response

    “In addition to this, the Trust has implemented a Divisional fractured neck of femur improvement programme, which is reported and monitored daily via the Divisional senior leadership team. Oversight of Divisional compliance with this pathway is also monitored via the Service Quality and Governance Group, which is chaired by the Executive Director of Nursing and Integrated Governance.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 5 October 2022

    Open published response

  9. Manchester South

    AI-generated summary

    James Robert Curry · 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 Robert Curry died at Tameside General Hospital on 18 November 2021 from bronchopneumonia after an accidental fall caused a fractured neck of femur. The report identified prolonged waiting in the emergency department, shortages of beds and theatre capacity, lack of orthogeriatric care, and surgery taking place outside the recommended timescale as substantive concerns.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide hip fracture surgery within NICE-compliant timescales

    Wider context from the report

    “1. The Inquest heard that a lengthy wait for an elderly patient with a hip fracture on a trolley in the Emergency Department will impact their physiological reserves and add to their pain. In Mr Curry’s case, the Inquest heard that the prolonged wait was due to a shortage of beds within the Trust. That situation is still the case; 2. Mr Curry needed an orthopaedic bed to enable him to have the operation. The evidence was that a shortage of beds meant that he could not be placed in one and had to go to AMU. As a consequence on admission he did not receive the orthogeriatric care envisaged by NICE in their guidance; 3. The Inquest heard that the operation should have taken place earlier than it did under the NICE guidance. The Inquest was told that the NICE guidance is based on ensuring the best outcomes for elderly patients with fracture neck of femur and reducing mortality. It did not due to a shortage of capacity in the Trust. The Inquest heard that the Trust was regularly not able to operate in timescales compliant with the NICE guidance. ”

    Source location

    James Robert Curry · 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

    Report surgery delays exceeding 36 hours, complete root cause analyses, and review findings weekly for learning and approved actions.

    Verbatim wording from the response

    “Where the Trust are not able to meet the 36 hour timeframe for surgery for patient with a fracture neck of femur a clinical incident report is submitted. Following the incident a root cause analysis is completed by the Trauma Coordinators to identify reasons for the delay and opportunities for learning. The root cause analysis investigations are then reviewed weekly in the “NOF Review Meeting” for comment, action and approval. This meeting is attended by the Clinical Lead for Neck of Femur, the Matron for Trauma and Orthopaedics and the Directorate Manager.”

    Source location

    Response from Tameside and Glossop Integrated Care
    Page 2 · response
    Published 29 September 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Monitor compliance with NICE hip-fracture guidance and submit daily data to the National Hip Fracture Database and related audit programme.

    Verbatim wording from the response

    “For assurance of performance with the National Institute for Health and Care Excellence (NICE) Clinical guidance the Surgery, Women’s and Children’s Division are monitoring compliance on an ongoing basis. The Trust submits data to the National Hip Fracture Database, which specifically looks at care for patients over the age of 60, who undergo surgery following a hip fracture. This includes data to improve care through quality improvement in line with NICE guidelines and the National Falls and Fragility Fracture Audit Programme (FFFAP). Data is submitted by the trauma co-ordinators daily. The Trust have implemented a Divisional fractured neck of femur improvement programme which is reported and monitored daily via the Divisional senior leadership team.”

    Source location

    Response from Tameside and Glossop Integrated Care
    Page 2 · response
    Published 29 September 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Operate a divisional fractured-neck-of-femur improvement programme with daily senior-leadership reporting and monitoring.

    Verbatim wording from the response

    “For assurance of performance with the National Institute for Health and Care Excellence (NICE) Clinical guidance the Surgery, Women’s and Children’s Division are monitoring compliance on an ongoing basis. The Trust submits data to the National Hip Fracture Database, which specifically looks at care for patients over the age of 60, who undergo surgery following a hip fracture. This includes data to improve care through quality improvement in line with NICE guidelines and the National Falls and Fragility Fracture Audit Programme (FFFAP). Data is submitted by the trauma co-ordinators daily. The Trust have implemented a Divisional fractured neck of femur improvement programme which is reported and monitored daily via the Divisional senior leadership team.”

    Source location

    Response from Tameside and Glossop Integrated Care
    Page 2 · response
    Published 29 September 2022

    Open published response

  10. Central and South East Kent

    AI-generated summary

    Helen Jennifer Turner · 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

    Helen Jennifer Turner was admitted with diarrhoea and vomiting and was diagnosed with a sigmoid colon obstruction. She later developed sepsis, colonic perforation and peritonitis, underwent surgery and further procedures, and died after her condition deteriorated. The report identified delays in confirming the obstruction, arranging stenting and operating to remove it; expert evidence stated that these delays diminished her chances of survival.

    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

    Delay in operating to remove bowel obstruction

    Wider context from the report

    “• There was a delay in operating on Mrs Turner to remove the bowel obstruction which did not take place until 20.04.15 by which stage her condition had deteriorated to a critical level. ”

    Source location

    Helen Jennifer Turner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in surgery following cancer diagnosis

    Wider context from the report

    “• The expert evidence heard at the Inquest found that Mrs Turner had a 90% chance of surviving the diagnosis of cancer and abdominal surgery to remove the tumour. Because of the delay in diagnosis and surgery, her chances of survival were diminished. ”

    Source location

    Helen Jennifer Turner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026