Recurring concern

Failure of echocardiography services to provide timely diagnostic assessment and follow-up

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First reported 13 Oct 2014•Latest report 10 Mar 2026

Definition

What this concern includes

Includes failures dedicated to the echocardiography service or pathway, including timely access or availability, performance of clinically indicated echocardiograms, and timely review, communication or follow-up of echocardiography results.

Not included

  • Excludes failures concerning other diagnostic investigations unless the report expressly ties them to the echocardiography service.
  • Excludes generic staffing, appointment, information-management or governance deficiencies that are not specifically dedicated to echocardiography.
  • Excludes clinical decisions or treatment failures occurring after echocardiography unless they concern the timely review, communication or follow-up of its results.
Reports
9

Distinct published reports

Individual concerns
10

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
15

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.

Department of Health and Social Care3
NHS Greater Manchester Integrated Care Board3
Department for Digital, Culture, Media and Sport1
Faculty of Intensive Care Medicine1
NHS Central East Integrated Care Board1
NHS England1
Northamptonshire Safeguarding Children Partnership1
North Middlesex University Hospital1
North West Anglia NHS Foundation Trust1
Oxford University Hospitals NHS Foundation Trust1
Royal College of Emergency Medicine1
Royal College of Radiologists1
Royal Free London NHS Foundation Trust1
Tameside and Glossop Integrated Care NHS Foundation Trust1
The Queen Elizabeth Hospital, King's Lynn1

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. City of London

    AI-generated summary

    Jennine Sasha Romeo · 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

    Jennine Sasha Romeo died on 29 May 2025 after developing multiorgan failure following complications of mitral valve surgery and subsequent re-do surgery. The January 2025 echocardiogram showing serious cardiac abnormalities was not clinically reviewed until May, after hospital outpatient appointments had been cancelled. The report identified concerns about the absence of systems to ensure timely review of results and a pathway for the echocardiography team to flag significant findings.

    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 ensuring timely review and consideration of echocardiography results

    Wider context from the report

    “As stated above, the evidence suggested that the outcome of a transthoracic echocardiogram performed in January 2025 at the North Middlesex University Hospital was not reviewed by any clinician until May 2025. It seems that the intention was for it to be reviewed at a valve clinic out-patient appointment, but appointments in February and March 2025 were cancelled by the hospital, and there is no evidence to suggest that the result was considered at a paper review by the Consultant on the 4th April 2025, not by any other clinical team at the hospital. There appears to be no system in place to ensure that a result such as this is viewed and considered by a member of a relevant clinical team in a timely manner, whether or not the planned out-patient appointment takes place as planned. Additionally, it seems that there is no relevant pathway for the echocardiography team to flag a result such as this to the clinical team. ”

    Source location

    Jennine Sasha Romeo · Prevention of Future Deaths report
    Page 3 · 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

    Lack of a pathway for echocardiography teams to flag results to clinical teams

    Wider context from the report

    “As stated above, the evidence suggested that the outcome of a transthoracic echocardiogram performed in January 2025 at the North Middlesex University Hospital was not reviewed by any clinician until May 2025. It seems that the intention was for it to be reviewed at a valve clinic out-patient appointment, but appointments in February and March 2025 were cancelled by the hospital, and there is no evidence to suggest that the result was considered at a paper review by the Consultant on the 4th April 2025, not by any other clinical team at the hospital. There appears to be no system in place to ensure that a result such as this is viewed and considered by a member of a relevant clinical team in a timely manner, whether or not the planned out-patient appointment takes place as planned. Additionally, it seems that there is no relevant pathway for the echocardiography team to flag a result such as this to the clinical team. ”

    Source location

    Jennine Sasha Romeo · 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

    Operate and update the echocardiography escalation protocol, including senior review routes and a new criterion for pulmonary hypertension findings.

    Verbatim wording from the response

    “Your Report raised a concern regarding the lack of system in place to escalate and review abnormal findings on transthoracic echocardiogram. We can assure you that the echocardiography department has an established escalation pathway and protocol on how to action significant abnormal results. The escalation protocol (attached as Appendix 1) has been operational since 2019 with criteria based on best practice and guidelines from the British Society for Echocardiography and includes significant valvular abnormalities, ventricular abnormalities, large pericardial collections, markedly enlarged vessels, abnormal masses and other miscellaneous findings. The pathway clearly outlines the action of escalation which, depending on the findings, will include either an on-call Cardiologist review on the day of the scan or a Cardiology Consultant review of results within 2 weeks.”

    Source location

    Response from North Middlesex University Hospital and the Royal Free Hospital
    Page 1 · response
    Published 12 March 2026

    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

    Automatically book cancelled appointments into the next available follow-up slot and escalate repeated service cancellations for senior clinical review.

    Verbatim wording from the response

    “Your report raised a concern regarding review of clinical results in a timely manner, whether or not the planned outpatient appointment takes place. Following this a revised process has been introduced to strengthen oversight of appointment cancellations. This has been operational since April 2026. If a patient has their appointment cancelled (by either the service, or patient) they are automatically booked into the next available follow-up appointment slot by the bookings team. If a patient has had their appointment previously cancelled by the service, where it is identified that their next appointment would also be cancelled, the case is escalated to the Cardiology service manager for senior review. The case is then discussed with the relevant clinicians to determine the most appropriate course of action and minimise delay in clinical review where necessary.”

    Source location

    Response from North Middlesex University Hospital and the Royal Free Hospital
    Page 2 · response
    Published 12 March 2026

    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 and annually review the echocardiography escalation pathway, including escalation of significant abnormalities and the added criterion for new pulmonary hypertension.

    Verbatim wording from the response

    “Your Report raised a concern regarding the lack of system in place to escalate and review abnormal findings on transthoracic echocardiogram. We can assure you that the echocardiography department has an established escalation pathway and protocol on how to action significant abnormal results. The escalation protocol (attached as Appendix 1) has been operational since 2019 with criteria based on best practice and guidelines from the British Society for Echocardiography and includes significant valvular abnormalities, ventricular abnormalities, large pericardial collections, markedly enlarged vessels, abnormal masses and other miscellaneous findings. The pathway clearly outlines the action of escalation which, depending on the findings, will include either on-call Cardiologist review on the day of the scan or a Cardiology Consultant review of results within 2 weeks.”

    Source location

    Response from North Middlesex University Hospital and the Royal Free Hospital
    Page 1 · response
    Published 12 March 2026

    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

    Automatically book cancelled appointments into the next available follow-up slot and escalate repeated service cancellations to the Cardiology service manager for senior review.

    Verbatim wording from the response

    “Your report raised a concern regarding review of clinical results in a timely manner, whether or not the planned outpatient appointment takes place. Following this a revised process has been introduced to strengthen oversight of appointment cancellations. This has been operational since April 2026. If a patient has their appointment cancelled (by either the service, or patient) they are automatically booked into the next available follow-up appointment slot by the bookings team. If a patient has had their appointment previously cancelled by the service, where it is identified that their next appointment would also be cancelled, the case is escalated to the Cardiology service manager for senior review. The case is then discussed with the relevant clinicians to determine the most appropriate course of action and minimise delay in clinical review where necessary.”

    Source location

    Response from North Middlesex University Hospital and the Royal Free Hospital
    Page 2 · response
    Published 12 March 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    An established echocardiography escalation pathway and protocol adequately address significant abnormal findings.

    Verbatim wording from the response

    “Your Report raised a concern regarding the lack of system in place to escalate and review abnormal findings on transthoracic echocardiogram. We can assure you that the echocardiography department has an established escalation pathway and protocol on how to action significant abnormal results. The escalation protocol (attached as Appendix 1) has been operational since 2019 with criteria based on best practice and guidelines from the British Society for Echocardiography and includes significant valvular abnormalities, ventricular abnormalities, large pericardial collections, markedly enlarged vessels, abnormal masses and other miscellaneous findings. The pathway clearly outlines the action of escalation which, depending on the findings, will include either an on-call Cardiologist review on the day of the scan or a Cardiology Consultant review of results within 2 weeks.”

    Source location

    Response from North Middlesex University Hospital and the Royal Free Hospital
    Page 1 · response
    Published 12 March 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    An established echocardiography escalation pathway and protocol are considered sufficient to address significant abnormal findings.

    Verbatim wording from the response

    “Your Report raised a concern regarding the lack of system in place to escalate and review abnormal findings on transthoracic echocardiogram. We can assure you that the echocardiography department has an established escalation pathway and protocol on how to action significant abnormal results. The escalation protocol (attached as Appendix 1) has been operational since 2019 with criteria based on best practice and guidelines from the British Society for Echocardiography and includes significant valvular abnormalities, ventricular abnormalities, large pericardial collections, markedly enlarged vessels, abnormal masses and other miscellaneous findings. The pathway clearly outlines the action of escalation which, depending on the findings, will include either on-call Cardiologist review on the day of the scan or a Cardiology Consultant review of results within 2 weeks.”

    Source location

    Response from North Middlesex University Hospital and the Royal Free Hospital
    Page 1 · response
    Published 12 March 2026

    Open published response
  2. Newcastle and North Tyneside

    AI-generated summary

    Thomas Colin Morrell · 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 Colin Morrell had hypertrophic obstructive cardiomyopathy and was admitted to hospital in October 2024 after initially being treated for abdominal issues before being found to be in heart failure. He underwent heart transplantation, which was complicated by massive bleeding and irreversible failure of the transplanted heart; support was withdrawn and he died on 3 December 2024. Concerns included delayed recognition of heart failure and the absence of a standard operating process for referring HOCM patients, as well as a lack of cardiac imaging between 2021 and 2024 to monitor deterioration.

    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 undertake interval cardiac scans or echocardiograms to check for deterioration

    Wider context from the report

    “(2) In 2019 an echocardiogram showed no changes to Mr Morrell's heart but by 6 July 2021 a cardiac MRI scan showed focal hypertrophy and patchy scarring within the heart, with functional impairment in the mild to moderate range. On 16 October 2024 an echocardiogram showed severe biventricular failure. There were no scans / echocardiograms undertaken between those dates to check for deterioration. Had the deterioration been detected sooner, I was told in evidence that there may have been an earlier opportunity to intervene prior to deterioration into end stage heart failure, which may have improved the prospects of surgical intervention. ”

    Source location

    Thomas Colin Morrell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Manchester South

    AI-generated summary

    Esme Vera Louise Atkinson · 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

    Esme Vera Louise Atkinson was born on 7 February 2024 and died at Stepping Hill Hospital on 17 March 2024 after suddenly stopping breathing. A post-mortem examination found a ventricular septal defect, and the report states that earlier identification would probably have prevented her death at that time. Concerns included missed opportunities to identify the defect, inadequate recognition of feeding and weight concerns, gaps in professional training and information sharing, and the absence of routine echocardiography and auditing of cardiac images in relevant circumstances.

    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 routine echocardiograms for babies born to mothers with diabetes

    Wider context from the report

    “4. There was no routine echocardiogram of a baby born of a mother with diabetes nationally although their risk of a defect was significantly higher than other babies and such a test would detect a baby with a ventricular septal defect at an early stage ”

    Source location

    Esme Vera Louise Atkinson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Whether additional fetal echocardiography is offered depends on individual risk assessment and the treating clinician’s discretion.

    Verbatim wording from the response

    “You raised specific concerns that there is no routine echocardiogram of babies born to a mother with diabetes and that in Esme’s case, although her mum’s identical twin had a heart defect, this did not trigger the protocol for a routine echocardiogram. NHS England encourages all trusts to follow the FASP criteria for offering screening for fetal anomalies. Additional screening for fetal anomalies may include a fetal medicine scan and/or a fetal echocardiogram for patients at higher risk of fetal anomalies for such as maternal diabetes, or having a first degree relative with a congenital heart disease (for example an affected parent or sibling). We agree that additional screening for Esme would have been a reasonable course of action, given the increased risk associated with a genetically identical maternal aunt with a heart defect.”

    Source location

    Response from Department of Health and Social Care
    Page 3 · response
    Published 18 June 2025

    Open published response
  4. Cambridgeshire and Peterborough

    AI-generated summary

    Christian James Gabriel Hobbs · 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

    Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.

    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 obtain echocardiography for critically unwell patients in shock

    Wider context from the report

    “POINT B - RE: ECHOCARDIOGRAPHY Christian had not had an echocardiogram prior to his arrest. This was a concerning feature of his care in the ED given he was critically unwell and in a shocked state. ”

    Source location

    Christian James Gabriel Hobbs · Prevention of Future Deaths report
    Page 15 · 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

    Include focused cardiac ultrasound for shock assessment in the emergency medicine training curriculum.

    Verbatim wording from the response

    “Point B – Echocardiography. Regarding your concern that echocardiography was not performed prior to cardiac arrest, we can confirm that the RCEM training curriculum at the time [1] did not include cardiac ultrasound for the purposes of shock assessment, it was only included as an adjunct in the setting of cardiac arrest. It would therefore have been an unreasonable expectation that a focused cardiac ultrasound for the assessment of shock should have taken place before cardiac arrest by the emergency medicine doctor. A subsequent curriculum update in 2021 did include focused cardiac ultrasound for shock assessment for emergency medicine doctors in their last years of training [2]. The RCEM also”

    Source location

    Response from Royal College of Emergency Medicine
    Page 1 · response
    Published 15 April 2025

    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

    Provide echocardiography training to trainees.

    Verbatim wording from the response

    “B. Echocardiography This case was not caused by an inability to perform an echocardiogram. Had cardiogenic shock been suspected, a Consultant Intensivist or an on duty Medical Registrar, who was also a trained Cardiology Registrar, could have performed the procedure. As was explained at the inquest hearing in October 2023, it is possible to train more clinicians to perform echocardiograms. However, for a clinician to maintain their accreditation to perform echocardiograms, it is obligatory to perform a certain number of echocardiograms annually. While Cardiologists and Intensivists routinely meet this requirement, it remains challenging for other specialty clinicians, including ED. Nevertheless, our trainees now receive echocardiography training.”

    Source location

    Response from North West Anglia NHS Foundation Trust
    Page 2 · response
    Published 15 April 2025

    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

    Review HiLLO descriptors and consider clarifying echocardiography training and skills requirements.

    Verbatim wording from the response

    “The most recent curriculum for doctors training in intensive care medicine was implemented in 2021. As with all postgraduate medical training curricula it meets, and is informed by, the requirements mandated by the General Medical Council (GMC). One requirement is that a specific course or accreditation cannot be specified. Instead, the GMC has asked that training curricula are modelled to describe a number of high-level capabilities (so called ‘High Level Learning Outcomes, or HiLLOs). The curriculum for intensive care medicine contains fourteen HiLLOs. The use of focused echocardiography is covered in HiLLO 6:”

    Source location

    Response from Faculty of Intensive Care Medicine
    Page 1 · response
    Published 15 April 2025

    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

    Consult on GPICS version 3 guidance, including standards for echocardiography access, image storage, training and quality assurance.

    Verbatim wording from the response

    “Together with the Intensive Care Society, the Faculty publishes the Guideline for the Provision of Intensive Care Services (GPICS). Over the last decade, GPICS has become the definitive reference for planning, commissioning and delivery of adult intensive care services in the UK. GPICS version 3 is currently at the consultation stage. In the chapter of GPICS version 3 titled ‘Cardiovascular Support’, it is noted that:”

    Source location

    Response from Faculty of Intensive Care Medicine
    Page 1 · response
    Published 15 April 2025

    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

    Work with hospital cardiology service providers to improve reliable access to emergent out-of-hours echocardiography.

    Verbatim wording from the response

    ““Whilst current guidelines recommend that hospitals who admit acute cardiology patients have access to echocardiography 24/7, this may not be universally available. Intensive care physicians have an important role in improving access to echocardiography out-of-hours to support / exclude the diagnosis of cardiac pathologies. This will ultimately facilitate triage. The sickest patients need to undergo emergent echocardiography by someone trained to British Society of Echocardiography (BSE) level 1 standard or higher.””

    Source location

    Response from Faculty of Intensive Care Medicine
    Page 2 · response
    Published 15 April 2025

    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

    Work with providers to gain assurance that critically ill patients have 24/7 access to transthoracic or focused echocardiography.

    Verbatim wording from the response

    “• CPICB will work with North West Anglia NHS Foundation Trust and other providers caring for similar patient groups to gain assurance that mechanisms are in place to ensure critically ill patients have 24/7 access to either transthoracic echocardiography or focused echocardiography. This process will be undertaken through Clinical Quality Review Meetings and is expected to be completed by 30 June 2025.”

    Source location

    Response from Cambridgeshire and Peterborough ICB
    Page 2 · response
    Published 15 April 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Pre-arrest focused cardiac ultrasound was not a reasonable expectation because the applicable emergency medicine curriculum did not include shock assessment.

    Verbatim wording from the response

    “Point B – Echocardiography. Regarding your concern that echocardiography was not performed prior to cardiac arrest, we can confirm that the RCEM training curriculum at the time [1] did not include cardiac ultrasound for the purposes of shock assessment, it was only included as an adjunct in the setting of cardiac arrest. It would therefore have been an unreasonable expectation that a focused cardiac ultrasound for the assessment of shock should have taken place before cardiac arrest by the emergency medicine doctor. A subsequent curriculum update in 2021 did include focused cardiac ultrasound for shock assessment for emergency medicine doctors in their last years of training [2]. The RCEM also”

    Source location

    Response from Royal College of Emergency Medicine
    Page 1 · response
    Published 15 April 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The case was not caused by inability to perform echocardiography; appropriately trained clinicians could have performed the procedure if cardiogenic shock was suspected.

    Verbatim wording from the response

    “B. Echocardiography This case was not caused by an inability to perform an echocardiogram. Had cardiogenic shock been suspected, a Consultant Intensivist or an on duty Medical Registrar, who was also a trained Cardiology Registrar, could have performed the procedure. As was explained at the inquest hearing in October 2023, it is possible to train more clinicians to perform echocardiograms. However, for a clinician to maintain their accreditation to perform echocardiograms, it is obligatory to perform a certain number of echocardiograms annually. While Cardiologists and Intensivists routinely meet this requirement, it remains challenging for other specialty clinicians, including ED. Nevertheless, our trainees now receive echocardiography training.”

    Source location

    Response from North West Anglia NHS Foundation Trust
    Page 2 · response
    Published 15 April 2025

    Open published response
  5. Manchester South

    AI-generated summary

    James Neil COCKBURN · 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 Neil Cockburn had severe aortic stenosis and was awaiting assessment for suitability for open heart surgery when he suffered a myocardial infarction and died at home on 26 May 2023. The report identified delays in cardiology appointments and essential tests, together with communication delays between NHS trusts caused by separate IT systems, as substantive concerns affecting treatment planning and decision-making.

    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

    Shortage of suitably qualified professionals to carry out essential cardiac tests

    Wider context from the report

    “The inquest heard that despite the referral being in August 2022 he had to wait months for his appointment due to the demand on cardiac services. This was significant across Greater Manchester but reflected a national picture of significant delays in patients waiting to see a cardiologist. As a consequence patient/s with cardiac issues are subject to delays in treatment plans and decision making regarding suitability for potentially lifesaving surgical procedures. In Mr Cockburn’s case he died whilst waiting assessment for his suitability for open heart surgery. It was 9 months since the first referral. The position the inquest was told is exacerbated due to significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals to carry them out. In his case the position was further exacerbated by delays in communication between two different trusts – NCA and MUFT. Their IT systems are completely separate and cannot transmit information into the others patient records easily. This meant that it was almost a month before the system at MUFT was updated with the test results from Salford Royal. ”

    Source location

    James Neil COCKBURN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver the Long-Term Workforce Plan, including expanded education, training, recruitment, retention, and strategic workforce planning.

    Verbatim wording from the response

    “NHS England is working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 4 July 2024

    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

    Support local services to recover elective care, reduce waiting times, improve diagnostic turnaround, and create additional capacity for complex and urgent care.

    Verbatim wording from the response

    “In February 2022, NHS England published the Delivery plan for tackling the COVID-19 backlog of elective care which sets out that the NHS is working to recover elective care over a three-year period. The plan includes the ambition to bring down waiting times for elective care, as well as improving diagnostic turnaround times and pathways. This includes plans to support local areas to create extra capacity within NHS services to focus on more complex areas, such as cardiac surgery, and improve the service provision for the most clinically urgent patients.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 4 July 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    NHS Trusts, rather than NHS England, are responsible for ensuring safe staffing levels in day-to-day hospital operations.

    Verbatim wording from the response

    “These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however NHS Trusts have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is in line with CQC Regulation 18, which states that providers must deploy enough suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 4 July 2024

    Open published response
  6. Oxfordshire

    AI-generated summary

    Beryl Dandridge · 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

    Beryl Dandridge fell at her nursing home on 23 January 2024 and sustained a periprosthetic hip fracture. Her ambulance attendance and surgery were delayed, including a delay while an echocardiogram was considered necessary; she underwent surgery on 27 January and died on 28 January 2024. Concerns related to conflicting clinical views about the need for echocardiography, responsibility for expediting it, and the subject expertise involved in the structured mortality review.

    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

    Unclear responsibility for expediting required echocardiograms

    Wider context from the report

    “2. Having determined that an echocardiogram was required before surgery could take place, it was unclear which clinicians was responsible for expediting such a scan in circumstances where the evidence indicated that delays in surgery is associated with poorer outcomes for vulnerable patients. ”

    Source location

    Beryl Dandridge · 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

    Clarify and agree the urgent echocardiogram process, including criteria, responsibilities, timescales, multidisciplinary discussion and escalation.

    Verbatim wording from the response

    “We already have a process for requesting urgent echocardiograms within the Trust. This process was reviewed and clarified at the Learning Multi-disciplinary Team meeting. This clarification included the rationale and criteria for requesting the urgent echocardiogram, who is responsible for making the request, acceptable timescales, the need for early multidisciplinary discussion, and an escalation process for when any delay through the normal route would be unacceptable. This process has been agreed with the Consultant Cardiology team and the escalation will go through the on call Consultant Cardiologist. Some members of the Orthogeriatrics team will also undergo training in focused bedside echocardiography to provide further capacity for urgent echocardiograms.”

    Source location

    Response from Oxfordshire County Council
    Page 2 · response
    Published 17 July 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    An existing Trust process governs urgent echocardiogram requests, including responsibility, timescales, multidisciplinary discussion and escalation.

    Verbatim wording from the response

    “We already have a process for requesting urgent echocardiograms within the Trust. This process was reviewed and clarified at the Learning Multi-disciplinary Team meeting. This clarification included the rationale and criteria for requesting the urgent echocardiogram, who is responsible for making the request, acceptable timescales, the need for early multidisciplinary discussion, and an escalation process for when any delay through the normal route would be unacceptable. This process has been agreed with the Consultant Cardiology team and the escalation will go through the on call Consultant Cardiologist. Some members of the Orthogeriatrics team will also undergo training in focused bedside echocardiography to provide further capacity for urgent echocardiograms.”

    Source location

    Response from Oxfordshire County Council
    Page 2 · response
    Published 17 July 2026

    Open published response
  7. Manchester South

    AI-generated summary

    Michael Kevin Amesbury · 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

    Michael Kevin Amesbury had extensive cardiac disease and became increasingly unwell while awaiting assessment for severe mitral regurgitation. He died in hospital after becoming unresponsive and undergoing cardiopulmonary resuscitation; post-mortem examination identified bilateral bronchopneumonia and aspiration of gastric contents, with heart failure contributing to reduced physiological reserves. The concerns included delays and problems in referrals between secondary and tertiary services, information-sharing and transfer of clinical records and images, and delays in cardiology assessment and trans-oesophageal echocardiography due to resource and appointment constraints.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient trans-oesophageal echocardiogram resources

    Wider context from the report

    “2. The evidence also indicated that there were delays in patients who had been identified as requiring cardiology input being seen in cardiology clinics due to availability of clinicians/appointment slots inquest. This was exacerbated where there was a need for trans-oesophageal echocardiogram due to resource issues. The inquest heard that this type of echocardiogram could be key in understanding the cardiac issues of a patient. ”

    Source location

    Michael Kevin Amesbury · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. Norfolk

    AI-generated summary

    DAVID JOHN MOUNTAIN · 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

    David John Mountain was found to have a slow heart rate, underwent permanent pacemaker insertion on 20 June 2014, and developed chest pain on the way home after discharge. He deteriorated and died on 23 June 2014; the report raised concern that bleeding and vascular damage were not fully investigated promptly and that echocardiogram results showing a mild to moderate bleed around the heart were unavailable until after 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

    Delayed availability of echocardiogram results

    Wider context from the report

    “Despite having had a permanent pacemaker inserted on 20 June 2014 and Mr Mountain developing chest pain on 21 June 2014, the risks recognised on the consent form, including risk of bleeding and vascular damage were not fully investigated and an Echocardiogram was not performed until afternoon of 23 June 2014. The results, which showed a mild to moderate bleed around the heart, were not available until after Mr Mountain’s death. ”

    Source location

    DAVID JOHN MOUNTAIN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and implement an electronic reporting system for test results, including echocardiography.

    Verbatim wording from the response

    “Alongside this, we are moving to an electronic reporting system for all test results including echocardiography. Scoping of this major IT project has commenced and we anticipate that it will be in place by the end of 2015. This will allow doctors access to reports immediately when they are entered onto the system and will eliminate the need to transfer a paper copy report from one area of the hospital to another.”

    Source location

    2014-0554-Response-by-The-Queen-Elizabeth-Hospital
    Page 1 · response
    Published 24 December 2014

    Open published response
  9. Manchester South

    AI-generated summary

    Mary Fenton · 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

    Mary Fenton was admitted to Tameside Hospital on 26 April 2014 needing an urgent heart pacemaker and died on 30 April 2014 after delays and missed opportunities. Concerns included limited cardiology cover and facilities, shortages of Isoprenaline, failures relating to capacity and consent, delays in inserting pacing wires, inadequate facilities to manage complications, and poor communication.

    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

    Unavailability of echocardiography facilities after 5.00pm

    Wider context from the report

    “2. After 5.00pm there is no facility for an echocardiogram to be performed at the hospital. (For Tameside Hospital) ”

    Source location

    Mary Fenton · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review out-of-hours CRI provision and explore procurement of a portable echocardiogram machine.

    Verbatim wording from the response

    “Currently, the provision of echocardiogram services is undertaken as a day case service between the hours of 9.00am and 5.00pm and this existing service is provided by the specialist CRI technicians. Due to the existing capacity and demand for the service, the existing provision can only currently provide an in hours service. Echocardiograms are and have been undertaken by qualified Consultants and Staff Grade Doctors as and when required. Going forward, the recent external cardiology service review and your concerns following the inquest into the death of Mrs Fenton have formed the basis for a service review specifically around the provision of CRI services. As part of this review, the procurement of a portable echocardiogram machine and out of hour provision is being explored as part of the wider service developments.”

    Source location

    2014-0443-Response-by-Tameside-Hospital
    Page 2 · response
    Published 13 October 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing capacity and demand mean echocardiography can currently be provided only during daytime hours, while out-of-hours provision is being explored.

    Verbatim wording from the response

    “Currently, the provision of echocardiogram services is undertaken as a day case service between the hours of 9.00am and 5.00pm and this existing service is provided by the specialist CRI technicians. Due to the existing capacity and demand for the service, the existing provision can only currently provide an in hours service. Echocardiograms are and have been undertaken by qualified Consultants and Staff Grade Doctors as and when required. Going forward, the recent external cardiology service review and your concerns following the inquest into the death of Mrs Fenton have formed the basis for a service review specifically around the provision of CRI services. As part of this review, the procurement of a portable echocardiogram machine and out of hour provision is being explored as part of the wider service developments.”

    Source location

    2014-0443-Response-by-Tameside-Hospital
    Page 2 · response
    Published 13 October 2014

    Open published response
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Data last updated 7 September 2026