Concerns raised 1
Failure to report or urgently highlight clinically significant incidental ED findings to the GP View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Paul Guy Robert Harries · 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
Paul Guy Robert Harries was diagnosed with an abdominal aortic aneurysm and was subsequently lost to follow-up after missing a surveillance scan. He later died at home in Brighton on 9 October 2024 from a ruptured AAA while awaiting an outpatient appointment. Concerns included the handling of missed appointments, the downgrading and delayed booking of an urgent referral, reliance on separate referral systems, and failure to consistently report significant incidental emergency-department findings to the GP.
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 report or urgently highlight clinically significant incidental ED findings to the GP
Wider context from the report “Incidental findings from tests conducted in the ED are not always reported to the GP where these may not relate to the presenting complaint. ED policy appears to remain inconsistent. This is especially important as it means a Patient with a significant condition, for which they are under their GP, may have a change in that condition identified at the ED which is not then always reported back or highlighted urgently to the GP .
” Source location Paul Guy Robert Harries · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all Emergency Department imaging reports, follow up incidental or relevant findings, and inform GPs where appropriate.
Verbatim wording from the response “The Lead Consultant for the Emergency Department (ED) at the Royal Sussex County Hospital has confirmed that there is now a system in place, introduced in 2026, to review all imaging reports obtained in the ED. The ED team check on incidental or relevant unrelated findings and ensure that follow-up arrangements are in place and/or the patient’s GP is informed. In addition, our hospital imaging reports are also available on the electronic system which the GPs access and review.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
21 Feb 2025 Lady Lola Kay Crouch · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2
Failure to include relevant diagnostic findings in the patient history View source Failure to inform patients of potential malignancy findings View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Lady Lola Kay Crouch · 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
Lady Lola Kay Crouch died at Broomfield Hospital on 26 February 2023 from multi-organ failure due to small bowel obstruction associated with leiomyosarcoma of the small intestine and abdominal adhesions. A December 2022 CT finding suggestive of malignancy was not followed up or communicated to her, and it was not included in her later hospital history. The report also identifies delayed medical review overnight because of doctor staffing levels.
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 include relevant diagnostic findings in the patient history
Wider context from the report “(1) Lady Lola was not informed of the findings of potential malignancy from a CT scan in December 2022. This was not followed up and was then not given as part of the history when Lady Lola attended hospital in February 2023.
” Source location Lady Lola Kay Crouch · Prevention of Future Deaths report
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 Failure to inform patients of potential malignancy findings
Wider context from the report “(1) Lady Lola was not informed of the findings of potential malignancy from a CT scan in December 2022. This was not followed up and was then not given as part of the history when Lady Lola attended hospital in February 2023.
” Source location Lady Lola Kay Crouch · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide patients with copies of their radiology reports through the NHS App, including summaries of clinical findings.
Verbatim wording from the response “As part of our digital improvement innovation project, we have signed up to the ‘NHS App’ radiology reporting service whereby patients now receive a copy of their own imaging reports to their personal NHS App. The reports include a summary of clinical findings that can be read by patients to improve communication and understanding of their own health record.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement changes and processes to ensure patients are properly informed of their imaging results.
Verbatim wording from the response “We have implemented the necessary changes to ensure that patients are properly informed of their imaging results, and embedded new processes within our surgical teams to make sure surgical colleagues are well supported overnight for urgent cases and when required the Consultants act down as per policy.” Source location Response from Mid & South Essex NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing radiology alerts, communication procedures and annual audits provide sufficient arrangements for timely review and patient communication of significant findings.
Verbatim wording from the response “Our policy ‘Communication of time critical or unexpected significant findings during diagnostic reporting’ MSEPO-21240’ makes clear that the referring clinician is responsible for delivery of any radiology they request. Where radiological imaging reports detect an unexpected, significant or time sensitive finding, our policy provides that a radiology alert is sent to the responsible consultant with the full report so that prompt action can be taken, including communication with the patient.” Source location Response from Mid & South Essex NHS Trust
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 referring clinician is responsible for delivering requested radiology results and communicating significant findings to patients.
Verbatim wording from the response “Our policy ‘Communication of time critical or unexpected significant findings during diagnostic reporting’ MSEPO-21240’ makes clear that the referring clinician is responsible for delivery of any radiology they request. Where radiological imaging reports detect an unexpected, significant or time sensitive finding, our policy provides that a radiology alert is sent to the responsible consultant with the full report so that prompt action can be taken, including communication with the patient.” Source location Response from Mid & South Essex NHS Trust
Open published response
26 May 2024 David SCOTT · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1
Failure to report potentially clinically significant vascular calcification in x-ray reports View source
Linked response
Warrington and Halton Teaching Hospitals NHS Foundation Trust
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AI-generated summary
David SCOTT · 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 Scott attended hospital with a non-healing knee wound and was later diagnosed with peripheral vascular disease and chronic limb-threatening ischaemia. His condition deteriorated, requiring an above-knee amputation and other surgery, and he later developed infected ulcers and osteomyelitis before receiving palliative care and dying on 7 October 2023. The principal concern was that vascular calcification visible on an x-ray was not recorded, potentially delaying investigation and treatment of peripheral vascular disease; concerns were also raised about the failure to refer him to tissue viability nursing during wound 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 report potentially clinically significant vascular calcification in x-ray reports
Wider context from the report “Having considered the second edition of the Standards for Interpretation and Reporting of Imaging Investigations produced by the Royal College of Radiologists and having heard oral evidence from a Consultant Vascular Surgeon that a non-healing wound in addition to vascular calcification evident on x-ray can be a clinical indicator for Peripheral Vascular Disease which would then trigger a further process of investigation, I am concerned that a finding that 'could be normal' and so conversely 'could be abnormal' was not recorded .
I am further concerned and that something of this nature, would not be expected to be noted in the x-ray report , it appearing to be considered standard practice for it not to be reported by both a Consultant in Emergency Medicine and Consultant Radiologist within Warrington Hospital .
This does not appear to be consistent with expected standards and poses a risk that future deaths may occur.
” Source location David SCOTT · Prevention of Future Deaths report
Open source report
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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 Mild vascular calcification does not correlate with peripheral vascular disease symptoms or severity, and knee X-rays are not used to diagnose it.
Verbatim wording from the response “As stated in the written evidence submitted to the inquest, vascular calcification is common in older patients and is often seen incidentally on imaging studies in patients without clinical features of PVD. Studies suggest the prevalence of vascular calcification increases with age, and it is not routinely reported unless clinical information on the imaging request is suggestive of a clinical diagnosis of PVD, the calcification is severe or is associated with an aneurysm. The presence and extent of vascular calcification on X-ray does not correlate with PVD symptoms or severity and for this reason, X-rays are not used in the diagnosis of peripheral vascular disease.” Source location Response from Warrington Hospitals
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Not reporting mild vascular calcification without clinical information suggesting peripheral vascular disease complies with national radiology standards and practice.
Verbatim wording from the response “Mr Scott’s knee X-Ray showed mild vascular calcification without evidence of an aneurysm and therefore, in the absence of clinical information suggestive of PVD on the imaging request, this finding was not mentioned in the report. Our Radiologists confirm this is in line with national practice and guidance (the Standards for Interpreting and Reporting of Imaging Investigations produced by the Royal College of Radiologists).” Source location Response from Warrington Hospitals
Open published response
20 Jul 2023 Peter John Harris · Prevention of Future Deaths report City of London
View report summary
Concerns raised 1
Failure to alert requesting teams to suspicious radiological findings treated as expected findings View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Barking, Havering and Redbridge University Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Barking, Havering and Redbridge University Hospitals NHS Trust
Alert referrers electronically to expected, unexpected, and newly detected cancers and critical or significant non-cancer findings, with verbal escalation for emergency findings.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Launch the Aptvision radiology referral system during the week commencing 30 October 2023.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Provide an electronic acknowledgement function for referrers to confirm receipt of finalised radiology reports and urgent notifications, supported by user training.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Require specialties to create shared mailboxes receiving imaging-report notifications alongside named consultants’ individual worklists.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Add the radiological requesting, review, and expectation process to the Chief Medical Officer’s three-day induction programme for new consultants.
View source
Barking, Havering and Redbridge University Hospitals NHS Trust
Develop a unified North-East London cancer-alert policy through collaborative clinical leadership work.
View source See 3 more actions
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AI-generated summary
Peter John Harris · 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
Peter John Harris was admitted with stage 4 metastatic lung cancer and recurrent pericardial effusion, suffered a cardiac arrest during treatment, developed multi-organ failure, and died on 10 June 2022. The principal concerns were that two scans with concerning findings were not seen and acted upon in a timely manner, including a 2020 scan indicating possible lung metastases and a 2022 scan suspicious for lung cancer. Ongoing concerns remained about whether unexpected or expected cancer findings would be appropriately highlighted and whether optional read receipts would adequately identify unread reports.
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 alert requesting teams to suspicious radiological findings treated as expected findings
Wider context from the report “Concern 1:
The Trust’s new policy is concerned with ensuring that unexpected cancer or other critical radiological findings are highlighted to the requesting team. However, the evidence at the inquest suggested that requesting team were not alerted to the suspicious outcome of the Deceased’s November 2020 scan because it was an expected finding; as stated above, I was told that the radiologist’s report was not escalated or alerted to the clinical or multi-disciplinary teams because the requesting form had indicated that the scan was to rule out malignancy and the outcome was not, therefore, treated as unexpected . I am concerned, therefore, that the same could happen again , despite the changes which have been made. I did not consider that ████████ was able to address this concern satisfactorily in his evidence.
” Source location Peter John Harris · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Alert referrers electronically to expected, unexpected, and newly detected cancers and critical or significant non-cancer findings, with verbal escalation for emergency findings.
Verbatim wording from the response “1. The Radiology department will alert/notify the referrer’s/requesters to all imaging with:” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
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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 Launch the Aptvision radiology referral system during the week commencing 30 October 2023.
Verbatim wording from the response “1. Aptvision Radiology Referral System – this new Radiology Requesting System is planned to live week commencing 30 October 2023.” Source location Response from Barking, Havering and Redbridge University Hospitals
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 an electronic acknowledgement function for referrers to confirm receipt of finalised radiology reports and urgent notifications, supported by user training.
Verbatim wording from the response “2. Acknowledgement Feature – Following a finalised radiological report, alongside any urgent notifications produced by radiology, an “acknowledgment” button is available. The “acknowledgment” button functionality allows all referrers involved in the initial radiology request to electronically select and acknowledge the receipt of the patient’s radiological report. The referral portal⁴ training material and learning outcomes for users, will emphasise the requirement of acknowledging results.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require specialties to create shared mailboxes receiving imaging-report notifications alongside named consultants’ individual worklists.
Verbatim wording from the response “5. Speciality Specific Mailboxes – will be created by the Specialties. This is as an additional safeguard where the notification of imaging report will be sent to a group email in addition to the named consultants individual worklist. Access to shared mailbox will be agreed by the Specialty.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
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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 Add the radiological requesting, review, and expectation process to the Chief Medical Officer’s three-day induction programme for new consultants.
Verbatim wording from the response “The Radiological Requesting, Review and Expectation process as detailed in this response will be added to the New Consultants 3-day Induction programme run by the CMO.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a unified North-East London cancer-alert policy through collaborative clinical leadership work.
Verbatim wording from the response “7. Collaborative Working - On 04 July 2023 Dr Ghadge, Consultant Radiologist and Clinical Lead for Radiology, presented the BHRUT’s Policy on Incidental Finding at the North-East London (NEL) Clinical Leadership Group for peer review. This group’s membership comprises of the Quality and Safety Leads (Consultant grade) from Whipps Cross Hospital, St Bartholomew Hospital, the Royal London Hospital, the Homerton and Newham Hospital. The progress made by BHRUT was recognised and the group members agreed to devise a Unified Incidental Finding Policy across NEL. At the last meeting (01 September 2023), it was agreed that a policy for Cancer Alerts would be developed whereas Critical non-cancer alerts would vary as per local needs. The next meeting planned is 01 December 2023.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
18 May 2023 Akash Dinesh Bhudia · Prevention of Future Deaths report East London
View report summary
Concerns raised 2
Lack of a process for adding alerts to normal communication methods for significant radiological findings View source Failure to highlight significant, unexpected, and important radiological findings to the referring clinician View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Medica
Update the Medica Alerts policy to require urgent notification of referrers for potential new TB diagnoses and advise that treatment changes may be needed.
View source
Medica
Circulate the updated Medica Alerts policy to all reporters.
View source
Medica
Work with clients to enact the 2022 Academy of Royal Colleges and RCR Alerts guidelines within local processes.
View source
Medica
Raise Urgent Findings for relevant cases until clients adjust their internal alert processes.
View source See 1 more action
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AI-generated summary
Akash Dinesh Bhudia · 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
Akash Bhudia had a persistent cough and was treated for presumed pneumonia before a follow-up chest X-ray showed worsening and new lung consolidation. He later coughed and vomited blood, could not be resuscitated, and a post-mortem examination found a pulmonary abscess most likely caused by tuberculosis. The principal concern was that significant X-ray findings suggestive of tuberculosis were not highlighted to the referring clinician, and that no alert process appeared to be in place to ensure timely action.
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 process for adding alerts to normal communication methods for significant radiological findings
Wider context from the report “The X ray on the 28 February 2022, which was carried out following treatment for pneumonia, showed an obvious progression in lung consolidation and was highly suggestive of tuberculosis (a new clinical diagnosis). Akash was not an in-patient in hospital at the time of the follow-up X ray. He had been discharged and was therefore not under the active management of a clinical team. The inquest heard that such significant, unexpected, and important changes should have been highlighted to the referring clinician. This was not done. There does not appear to be a process in place for an alert to be added to the normal communication method to ensure that such significant, unexpected, and important findings are acted upon in a timely manner.
The inquest also heard that the incidence of TB is rising in certain areas of the UK and that it is important that radiologists recognise TB changes and that these are duly highlighted to the referrer.
” Source location Akash Dinesh Bhudia · Prevention of Future Deaths report
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 Failure to highlight significant, unexpected, and important radiological findings to the referring clinician
Wider context from the report “The X ray on the 28 February 2022, which was carried out following treatment for pneumonia, showed an obvious progression in lung consolidation and was highly suggestive of tuberculosis (a new clinical diagnosis). Akash was not an in-patient in hospital at the time of the follow-up X ray. He had been discharged and was therefore not under the active management of a clinical team. The inquest heard that such significant, unexpected, and important changes should have been highlighted to the referring clinician. This was not done. There does not appear to be a process in place for an alert to be added to the normal communication method to ensure that such significant, unexpected, and important findings are acted upon in a timely manner.
The inquest also heard that the incidence of TB is rising in certain areas of the UK and that it is important that radiologists recognise TB changes and that these are duly highlighted to the referrer.
” Source location Akash Dinesh Bhudia · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Medica Alerts policy to require urgent notification of referrers for potential new TB diagnoses and advise that treatment changes may be needed.
Verbatim wording from the response “Since the inquest Medica have edited the Medica Alerts policy to include a potential new diagnosis of TB as a reason to raise an urgent notification to referrers. The alert and the report should advise the referrer that a change of treatment may be required.” Source location Response from Medica Group
Open published response
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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 Circulate the updated Medica Alerts policy to all reporters.
Verbatim wording from the response “This new policy has been circulated to all reporters and a communication from me has highlighted the findings of the inquest to all reporters.” Source location Response from Medica Group
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 clients to enact the 2022 Academy of Royal Colleges and RCR Alerts guidelines within local processes.
Verbatim wording from the response “Medica will work with Clients to enact the Academy of Royal College/RCR Alerts guidelines 2022 as Clients wish to/are able to integrate the process locally. I note the Academy of Royal Colleges advice that ‘open TB’ should receive a Critical Alert. This is not a process in place in any NHS Trust to my knowledge at this time. Medica will raise Urgent Findings until Clients adjust their internal processes.” Source location Response from Medica Group
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 Raise Urgent Findings for relevant cases until clients adjust their internal alert processes.
Verbatim wording from the response “Medica will work with Clients to enact the Academy of Royal College/RCR Alerts guidelines 2022 as Clients wish to/are able to integrate the process locally. I note the Academy of Royal Colleges advice that ‘open TB’ should receive a Critical Alert. This is not a process in place in any NHS Trust to my knowledge at this time. Medica will raise Urgent Findings until Clients adjust their internal processes.” Source location Response from Medica Group
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 Clients are responsible for integrating the 2022 Alerts guidelines into local processes; until then, Medica will raise Urgent Findings.
Verbatim wording from the response “Medica will work with Clients to enact the Academy of Royal College/RCR Alerts guidelines 2022 as Clients wish to/are able to integrate the process locally. I note the Academy of Royal Colleges advice that ‘open TB’ should receive a Critical Alert. This is not a process in place in any NHS Trust to my knowledge at this time. Medica will raise Urgent Findings until Clients adjust their internal processes.” Source location Response from Medica Group
Open published response
22 Oct 2022 KEITH RUPERT DIMOND · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 1
Failure to communicate the iliac artery aneurysm diagnosis to treating clinicians View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
East Kent Hospitals University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
East Kent Hospitals University NHS Foundation Trust
Implement and expand Sunrise digital clinical documentation, results access and patient-observation recording across the organisation.
View source
East Kent Hospitals University NHS Foundation Trust
Continue improving Sunrise to support record-keeping quality and patient safety.
View source
East Kent Hospitals University NHS Foundation Trust
Revisit clinician training so staff can access all parts of the clinical record.
View source
East Kent Hospitals University NHS Foundation Trust
Ensure surgical clinicians understand their medical-record access responsibilities and include this requirement in new-staff induction.
View source See 1 more action
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AI-generated summary
KEITH RUPERT DIMOND · 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
Keith Dimond died on 24 November 2021 at Queen Elizabeth Queen Mother Hospital following a catastrophic bleed from a ruptured iliac artery aneurysm, with anticoagulation contributing to the excessive bleeding. Concerns included communication failures about the known iliac artery aneurysm, lack of information about bleeding risks when anticoagulation was prescribed, delayed escalation when he deteriorated, and haematology advice on anticoagulation not being followed on two occasions.
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 communicate the iliac artery aneurysm diagnosis to treating clinicians
Wider context from the report “(1) Treating Clinicians stated they were not aware of the diagnosis of Iliac Artery Aneurysm previously made at the Trust in August 2019 even though this was set out in the medical records and made at the same time as the diagnosis of Aortic Abdominal Aneurysm that was known. A abdominal surgery and anticoagulation were undertaken without consideration of this information.
” Source location KEITH RUPERT DIMOND · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and expand Sunrise digital clinical documentation, results access and patient-observation recording across the organisation.
Verbatim wording from the response “The Trust has become more digitally mature as an organisation; there have been several developments which have significantly improved the clarity and accessibility of our medical records. In October 2020, we launched Sunrise which provides ordering and viewing of test results. This was followed by the introduction of moving the documentation of the A&E clinical notes onto this system. Following on from this in June 2021 Sunrise was launched onto the wards for all clinical documentation and now includes patient clinical observations (blood pressure, heart rate etc). These significant improvements enable the clinical teams to access digitally the clinical notes and important results in one place which are accessible from anywhere within the organisation.” Source location Response from East Kent Hospitals University
Open published response
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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 Continue improving Sunrise to support record-keeping quality and patient safety.
Verbatim wording from the response “We continue to strive to improve the Sunrise system to support the quality of our record keeping and patient safety and are revisiting training to ensure all clinicians know how to access all parts of the clinical record.” Source location Response from East Kent Hospitals University
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 Revisit clinician training so staff can access all parts of the clinical record.
Verbatim wording from the response “We continue to strive to improve the Sunrise system to support the quality of our record keeping and patient safety and are revisiting training to ensure all clinicians know how to access all parts of the clinical record.” Source location Response from East Kent Hospitals University
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 Ensure surgical clinicians understand their medical-record access responsibilities and include this requirement in new-staff induction.
Verbatim wording from the response “In addition, our surgical site leads are ensuring all the clinicians in the department including seniors, understand their responsibility regarding accessing of medical records in line with GMC good medical practice and this will also be part of our induction for new staff. This case will be discussed at departmental morbidity and mortality meetings Trust wide for additional learning and the individual clinicians involved to include their personal reflection and learning within their annual appraisal.” Source location Response from East Kent Hospitals University
Open published response
17 Sep 2017 Paul James Maddox · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1
Failure of the laboratory to ring through significant downward haemoglobin trends for urgent clinical review View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Paul James Maddox · 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
Paul James Maddox was admitted to hospital with vomiting and subsequently developed severe internal bleeding after a fall in haemoglobin was not acted upon. He underwent emergency surgery after deteriorating, but died from massive gastrointestinal bleeding with disseminated intravascular coagulopathy. The principal concern was the missed opportunity to detect, investigate and treat the bleeding, with strategies to prevent recurrence still described as work in progress at the inquest.
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 of the laboratory to ring through significant downward haemoglobin trends for urgent clinical review
Wider context from the report “In spite of a Trust Root Cause Analysis Report identifying a missed opportunity before 13th April 2017 the court has been told at inquest that strategies to avoid a repeated failure were still work in progress.
The missed opportunity was not acting upon a reducing trend in a haemoglobin result.
This is simply not good enough as this issue should have been fixed during the Root Cause analysis investigation and before the report was approved as soon as the error became evident.
During the course of the inquest evidence was heard from several doctors including a surgeon and it was suggested that “when there is a downward trend in haemoglobin of 10% or more the laboratory should always ring through the result as a potential surgical emergency for the urgent review of clinicians ”
The court brings this to the attention of the Trust and for confirmation as to when a solution to this problem has been implemented
” Source location Paul James Maddox · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Change the laboratory IT system and issue staff instructions on revised standard operating procedures for haemoglobin reporting.
Verbatim wording from the response “• Changes to the lab IT system have been made and an action notice has been issued to all staff informing them of the agreed changes to our standard operating procedure around Hb reporting” Source location 2017-0220-Response-by-Wirral-University-Teaching-Hospital
Open published response
22 Jun 2017 Constance Connolly · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1
Failure to document significant findings and required follow-up investigations in discharge information View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
King'S College Hospital NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
King'S College Hospital NHS Foundation Trust
Send formal discharge notifications to GPs after self-discharge, including relevant tests, assessments and follow-up arrangements.
View source
King'S College Hospital NHS Foundation Trust
Implement mandatory suspected and confirmed diagnoses, author and senior clinician fields on Emergency Department discharge letters to GPs.
View source
King'S College Hospital NHS Foundation Trust
Develop a Trust-wide best-practice guide for discharge notifications and clinic letters, including self-discharge requirements, with local CCG collaboration.
View source
King'S College Hospital NHS Foundation Trust
Upgrade the Emergency Department tracking system to distinguish completed, booked and pending investigations on GP discharge notifications.
View source See 1 more action
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AI-generated summary
Constance Connolly · 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
Constance Connolly died at home on 8 March 2016 from disseminated Nocardia infection, with severe chronic obstructive airways disease also recorded. She declined hospital admission, and planned outpatient investigations were not completed. The report identified concerns about inadequate follow-up, failures in handover and communication, incomplete discharge information, and the failure to arrange a replacement scan appointment, describing these as a system failure in urgent follow-up after discharge from A&E.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to document significant findings and required follow-up investigations in discharge information
Wider context from the report “There are four matters in the circumstances which cause concern
1. The doctor who ordered the scan did not conduct any follow up to see that it had been performed. The consultant chest physician said that handover of care was dangerous time and that it was his duty to do so.
2. The referring doctor notified the GSTT community palliative care team of the need to organize a MRI scan, on the understanding that the team was taking over care. The consultant in the palliative care team explained that their role was to advise the doctor responsible for care, which was at the time, the general practitioner. The referring doctor did not inform the general practitioner.
3. The discharge note to the GP from the A&E indicated a diagnosis of stroke (presumed before CT scan), did not mention the CT finding of cerebral lesions that may be metastases, nor the need for EMI scan and further investigation to conform diagnosis, nor the booking of a MRI scan
4. A member of the palliative care team rang the A&E department and was told that the scan appointment was the next day (17th). When the patient and her mother attended the next day, she was told that there was no appointment. Evidence was heard that the booking, which was on the basis of being an in-patient, is automatically cancelled if the patient becomes an out-patient and the clinical referral cannot be transferred to an outpatient appointment. A new referral and form needed to be completed. So the patient went home, and no further appointment was made.
The above evidence suggests a system failure in handover of patients who leave A&E with the need for urgent follow up.
” Source location Constance Connolly · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send formal discharge notifications to GPs after self-discharge, including relevant tests, assessments and follow-up arrangements.
Verbatim wording from the response “Steps have been taken to ensure that regardless of patients self-discharging, a formal Discharge Notification is always sent to a patient’s GP, setting out all relevant tests/assessments performed and any follow-up arrangements if applicable. Responsibility sits with the admitting Consultant and Ward Managers, and this will be included in the junior doctors’ induction information package.” Source location 2017-0201-Response-by-Kings-College-Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement mandatory suspected and confirmed diagnoses, author and senior clinician fields on Emergency Department discharge letters to GPs.
Verbatim wording from the response “• There is currently a national recommendation from the Royal College of Emergency Medicine to improve and standardise communication from all Emergency Departments to GPs by October 2017 (the “ECDS” or Emergency Care Data Set). The ED’s IT team are working to implement this and this will include a mandatory ‘suspected and confirmed diagnoses’ step on all ED discharge letters to GPs with details of who wrote the discharge notification and the identity of the senior clinician overseeing the patient’s care.” Source location 2017-0201-Response-by-Kings-College-Hospital
Open published response
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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 a Trust-wide best-practice guide for discharge notifications and clinic letters, including self-discharge requirements, with local CCG collaboration.
Verbatim wording from the response “• The Trust is developing a Trust-wide best practice guide on Discharge Notification and clinic letter writing for clinical staff, in collaboration with the local CCGs. This will include clarification that a discharge notification is required for all patients who self-discharge.” Source location 2017-0201-Response-by-Kings-College-Hospital
Open published response
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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 Upgrade the Emergency Department tracking system to distinguish completed, booked and pending investigations on GP discharge notifications.
Verbatim wording from the response “• The ED tracking system (Symphony) is planned for an upgrade, which is due by October 2017. This will enable ED GP Discharge Notifications to highlight and distinguish which investigations have been done (ideally with a result if verified), which are booked and which are still pending.” Source location 2017-0201-Response-by-Kings-College-Hospital
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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 The concerns raised did not cause or contribute to the death, and the inquest found no failures of care contributed to it.
Verbatim wording from the response “As a preliminary point, we note that none of the concerns raised in the Report caused or contributed to Mrs Connolly’s death in light of the Conclusion reached at the Inquest hearing on 24 May 2017, namely “Natural causes contributed to by unintended consequences of necessary medical treatment”. The Report in particular states that no failures of care contributed to Mrs Connolly’s death.” Source location 2017-0201-Response-by-Kings-College-Hospital
Open published response
Concerns raised 1
Lack of a radiology protocol for non-cancerous significant and potentially life-threatening findings View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Barnsley Hospital NHS Foundation Trust
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AI-generated summary
Mr John Higgs · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr John Higgs died at Barnsley General Hospital on 18 November 2015 from a ruptured abdominal aortic aneurysm. A CT scan in March 2011 had identified the aneurysm, but the finding was not communicated to Mr Higgs, other clinicians, or his general practitioner. The report raised concern that the Trust’s current system for communicating unexpected, significant non-cancerous radiological findings remained reliant on one doctor noticing and recording the information, with no red-flag facility or equivalent protocol.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a radiology protocol for non-cancerous significant and potentially life-threatening findings
Wider context from the report “The inquest heard that the Trust now relies on an electronic system rather than the paper system as it did in 2011. However, any unexpected significant/serious radiological finding are still included in a report that is only sent to the Consultant in charge of the care and it is a matter for that doctor to notice that part of the report and to input this information on the system as a message. In essence, the process appears to be the same, it the mode of recording the information that had changed from paper to computer. No other measures have been put in place and the system is still reliant on one doctor noticing and recording the information. In addition, the Court heard there was no facility to place a “red flag” on the system to increase the likelihood of other clinicians being made aware of these unexpected and significant findings.
The Trust has a radiology protocol for “unexpected cancer pathology” where the results are sent to the treating Consultant but also sent to the MDT Cancer Co-ordinator for action but no such protocol exists for non- cancerous but significant and potentially life threatening findings .
The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to “unexpected (non-cancerous) radiological findings because HMAC ████████ is concerned that this situation could occur again.
” Source location Mr John Higgs · Prevention of Future Deaths report
Open source report
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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 Existing Guidance and ICE electronic reporting systems are considered sufficient to significantly reduce the risk of similar radiological communication failures and future deaths.
Verbatim wording from the response “████████ confirms the combination of the new Guidance, advice sought and the electronic reporting systems (ICE) now in place would significantly reduce the risk of a similar incident occurring in the future. The radiologist would be able to flag up a serious incidental finding to the treating clinician for their prompt action.” Source location John-higgs-Response
Open published response
4 Apr 2017 Christina Ingrid Smith · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 3
Failure to communicate identified thoracic aneurysms to patients and GPs View source Failure to inform GPs of identified thoracic aneurysms View source Failure to inform patients of identified thoracic aneurysms View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Christina Ingrid Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christina Ingrid Smith was referred to Yeovil District Hospital on 30 March 2016 and returned later that day for investigation of a suspected abdominal aneurysm. She deteriorated overnight and died at home; the inquest concluded that she died from a naturally occurring haemorrhage associated with a ruptured dissecting aortic aneurysm. Concerns included that her thoracic aneurysm was not communicated to her or her GP and was not placed under surveillance.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate identified thoracic aneurysms to patients and GPs
Wider context from the report “(3) There appears to have been a breakdown in communication with regard to advising both Mrs Smith and her GP as to the existence of the Thoracic Aneurysm .
” Source location Christina Ingrid Smith · Prevention of Future Deaths report
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 Failure to inform GPs of identified thoracic aneurysms
Wider context from the report “(1) A report on Mrs Smith of 2011 identified both an Abdominal Aneurysm and a Thoracic Aneurysm. It appears Mrs Smith was never told of the existence of the Thoracic Aneurysm. It appears Mrs Smith's GP was never told of the existence of the Thoracic Aneurysm.
” Source location Christina Ingrid Smith · Prevention of Future Deaths report
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 Failure to inform patients of identified thoracic aneurysms
Wider context from the report “(1) A report on Mrs Smith of 2011 identified both an Abdominal Aneurysm and a Thoracic Aneurysm. It appears Mrs Smith was never told of the existence of the Thoracic Aneurysm. It appears Mrs Smith's GP was never told of the existence of the Thoracic Aneurysm.
” Source location Christina Ingrid Smith · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.