Recurring concern

Unsafe updating of clinical policies and guidance

First to latest report 23 Oct 2013 — 24 Oct 2025

Reports that mention this concern
21
Times this concern has been raised
26
Stated actions linked to this concern
31

What this concern includes

Includes failures in the dedicated clinical-policy and guidance-updating process, including identifying the need for revision, resolving ambiguity, incorporating external guidance, approving changes, communicating them and implementing associated safety actions.

What is not included
  • Excludes generic staff training, communication, documentation or governance deficiencies unless they directly concern updating or implementing clinical policies and guidance.
  • Excludes operational protocol changes that are not clinical policies or guidance, including non-clinical procedures and local operational instructions.
  • Excludes failures to follow an otherwise current and clear policy or guidance when no deficiency in updating, revising or implementing the policy itself is identified.
  • Excludes deficiencies in the substantive clinical care, equipment or staffing arrangements where no clinical-policy or guidance-updating failure is asserted.

Reports and published responses 21 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Nottinghamshire

    AI-generated summary

    Sophie Louise TOWLE · 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

    Sophie Louise TOWLE died at Kings Mill Hospital on 27 May 2024 after suffering a large pulmonary embolus originating from a deep vein thrombosis in her left leg. The report describes concerns about the management of an inserted foreign object, VTE risk assessment and related policy and training, mental health services for patients with personality disorders, staffing levels, and cross-sector communication and working.

    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

    Ineffective communication of foreign-object insertion policy and guidance to staff

    Wider context from the report

    “4. The policy and procedures around the management of insertion of foreign objects for SFH I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance. It is not a robust policy in its terms. Further, I am concerned that it does not make any reference to consultation of mental health services, whether local or acute, at all. Given that the policy recognises that in the majority of cases where management of insertion of foreign objects the patient has a mental health condition, I find this particularly concerning. Based on the evidence that I have heard, I am also concerned that there is no effective communication of the policy and guidance to Trust staff on this issue. ”

    Source location

    Sophie Louise TOWLE · Prevention of Future Deaths report
    Page 5 · 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 specific, clear and robust policy guidance for managing foreign-object insertion

    Wider context from the report

    “4. The policy and procedures around the management of insertion of foreign objects for SFH I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance. It is not a robust policy in its terms. Further, I am concerned that it does not make any reference to consultation of mental health services, whether local or acute, at all. Given that the policy recognises that in the majority of cases where management of insertion of foreign objects the patient has a mental health condition, I find this particularly concerning. Based on the evidence that I have heard, I am also concerned that there is no effective communication of the policy and guidance to Trust staff on this issue. ”

    Source location

    Sophie Louise TOWLE · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement and approve a new guideline for managing deliberately inserted foreign bodies, including clear MDT and mental-health consultation requirements.

    Verbatim wording from the response

    “Upon conclusion of the Inquest, a comprehensive review of the SOP for deliberately inserted foreign bodies, as initially presented to HM Coroner, was undertaken. This review was conducted with the support and oversight of the Governance Support Unit to ensure rigorous examination and improvement of the procedure.”

    Source location

    Response from Sherwood Forest Hospitals NHS Foundation Trust
    Page 2 · response
    Published 31 October 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

    Disseminate the approved foreign-bodies guideline to staff involved in managing patients presenting with deliberately inserted foreign bodies.

    Verbatim wording from the response

    “On 28th November 2025, the document entitled “Management of Deliberately Inserted Foreign Bodies Guideline” was formally ratified at the Surgery, Anaesthetics and Critical Care Divisional Governance meeting. The final approved guideline is now available on the Trust intranet for clinicians to access and has been disseminated to all staff directly involved in the management of patients presenting with deliberately inserted foreign bodies.”

    Source location

    Response from Sherwood Forest Hospitals NHS Foundation Trust
    Page 3 · response
    Published 31 October 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

    Trial a joint physical and mental health policy for managing patients who insert foreign bodies, including joint meetings and impact review.

    Verbatim wording from the response

    “Staff at Nottinghamshire Healthcare Foundation Trust (NHFT) and Sherwood Forest Hospital Trust (SFHT) have collaborated on creating a joint management policy that provides guidance to staff on the management of patients who have inserted a foreign body. This includes the recommendation of joint meetings to support joined up collaborative care for patients requiring support from both services. This is being trialled for three months, and the impact of its use will be reviewed.”

    Source location

    Response from Nottingham Healthcare NHS Foundation Trust
    Page 1 · response
    Published 31 October 2025

    Open published response

  2. Avon

    AI-generated summary

    Sarah Jayne Lewis · 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

    Sarah Jayne Lewis, who had severe ME/CFS and was largely bedbound, was found deceased at home on 9 August 2024 after taking an overdose with the intention of ending her life. The inquest concluded suicide, with acute toxicity recorded as the cause of death. Concerns included inconsistent national provision of ME services, limited research and treatment options, insufficient professional understanding and training, and unclear implementation of updated NICE guidance.

    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 commissioning bodies to fully consider or implement NICE ME guidance

    Wider context from the report

    “(4) NICE issued update guidance relatively recently but it is not clear whether this has been fully considered or implemented by commissioning bodies around the country. ”

    Source location

    Sarah Jayne Lewis · 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

    Develop and publish ME/CFS guidance recommending assessment and skills for specialist services.

    Verbatim wording from the response

    “Our guideline on myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management [NG206] makes recommendations on the assessment and skills required for such a specialist service and NICE staff supported the development of the delivery plan.”

    Source location

    Response from National Institution for Health and Care Excellence
    Page 2 · response
    Published 15 July 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

    Support development of the cross-government ME/CFS delivery plan.

    Verbatim wording from the response

    “In the cross-government final delivery plan for ME/CFS published on 22 July 2025, it was noted that NHS England has completed a stocktake of existing ME/CFS services. Following this, NHSE will publish a template service specification for mild and moderate ME/CFS which will be disseminated to all ICBs to inform their commissioning decisions and support quality of local service provision to match local needs.”

    Source location

    Response from National Institution for Health and Care Excellence
    Page 1 · response
    Published 15 July 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

    Explore whether to prescribe a specialised service for people with very severe ME/CFS.

    Verbatim wording from the response

    “NHS England remains committed to collaborating with DHSC on the implementation of the ME/CFS Final Delivery Plan, with a view to supporting integrated care boards to ensure equitable access and evidence-based care, including implementation of the 2021 NICE guidance on ME/CFS. This partnership will support the integration of best practices and insights to enhance service quality and consistency across the system. More specifically, within the ME/CFS Final Delivery Plan, NHS England will co-design resources for systems to improve services for mild and moderate ME/CFS. Additionally, DHSC, with NHS England, will explore whether a specialised service should be prescribed by the Secretary of State for Health for very severe ME/CFS.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 15 July 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

    Implementation of NICE guidance through service commissioning and delivery is the responsibility of the relevant NHS body.

    Verbatim wording from the response

    “As mentioned above, service commissioning and delivery is the responsibility of the relevant NHS body.”

    Source location

    Response from National Institution for Health and Care Excellence
    Page 2 · response
    Published 15 July 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

    NICE guidelines are not mandatory, although commissioners are expected to take them fully into account and work towards implementation.

    Verbatim wording from the response

    “I understand that the National Institute for Health and Care Excellence (NICE) will be replying separately. I would like to reassure you that whilst NICE guidelines are not mandatory, the Government does expect healthcare commissioners to take the guidelines fully into account in designing services to meet the needs of their local population and to work towards their implementation over time. NICE has also recently published a Clinical Knowledge Summary on ME/CFS, available at the following link: Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) | Health topics A to Z | CKS | NICE.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 15 July 2025

    Open published response

  3. Oxfordshire

    AI-generated summary

    David Vincent Tighe · 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 Vincent Tighe, a 59-year-old man receiving chemotherapy for cancer, was admitted to hospital with chemotherapy-induced enterocolitis. During his treatment, bile aspiration occurred after insufficient monitoring and displacement of a Ryles tube, contributing to bronchopneumonia and sepsis, from which he died. The principal concerns were the absence of a specific Ryles tube policy and the use of a narrowly focused structured review that could miss care or procedural problems.

    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

    Absence of a specific policy for management of Ryles tubes

    Wider context from the report

    “Absence of a Ryles tube policy: 1. At the time of David’s death there was no separate policy for Ryles tubes, and clinicians were required to apply the modest Royal Marsden Manual guidance, and/or note that the practice consideration and care requirements for Ryles tubes were not dissimilar to that for nasogastric tubes used for enteral administration, as per the Trust’s “Insertion, Use and Care of Nasogastric Feeding Tubes in Adults: Policy and Procedure”, October 2018 (“NG feeding tube policy”), which provided limited advice. Evidence was given that a Ryles tube policy was required and that there was motivation at the Trust to provide one, albeit none has been forthcoming in the 20 months since David’s death. Evidence was also given that an NG tube “Position Record” for recording “Repeat Position Checks” was in use for Ryles tubes (similar to the “Nasogastric Feeding Tubes Position Record - Repeat Position Checks” document at Appendix 11 / page 53 of 55 of the Trust’s NG feeding tube policy), but no several staff were unaware of such a document existing for Ryles tubes, and no such Ryles tubes records were ever disclosed. Expert evidence was given that it was suboptimal care not to have a specific policy for the management of Ryles tubes given the risks associated with such an invasive procedure that required ongoing monitoring. At the time of the inquest, the Trust’s expressed intention was to provide a Ryles tube policy, and assistance was said to have been requested from the Shelford Group (an external body), although conversations about such a policy were said to have started within the Trust itself, as early as April or May of 2023. It is therefore unclear whether a Ryles tube policy would ever be produced notwithstanding one appears to be accepted as being required. The absence of policy where a need has been identified creates an obvious risk of death to future patients, due to the absence of guidance and procedure to assist clinicians undertaking such an invasive procedure. Use of a narrowly focussed structured review by a treating clinician: 2. On 18.03.2023 the Trust undertook a Structured Review to consider learning from David’s death. Evidence was given that the Structured Review was intended to be narrow in focus, as opposed to a more comprehensive serious incident report. As a result, it did not involve taking information from staff, but was a 2-hour review of medical records across five different areas, undertaken in a highly pressured environment. The Structured Review consequently overlooked considering several issues including: (i) missing bile drainage entries. (ii) missing clinical observations contrary to Trust policy (“Recognising the Acutely Ill and Deteriorating Adult Patient (RAID) Policy, April 2021). (iii) the absence of Repeat Position Checks for the Ryles tube. (iv) the absence of any written record of family concerns that were raised with a ward sister. Evidence was given by an author of the Structured Review that he considered its scope was in fact too limited, and in future, he would advise suspending such a narrow review. That author was also a clinician involved with David’s care in spite of the potential for conflict being correctly raised with the Trust in advance. Any inability to adequately investigate such incidents, without undue restriction in scope, without time pressure, and without any appearance of conflict or bias, creates a risk of death to future patients, as oversights or omissions in care, policy or procedure that may be missed by a narrow review, may remain unidentified and unremedied. ”

    Source location

    David Vincent Tighe · 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

    Review current practice and develop a Trust-wide policy for managing Ryles tubes used for aspiration drainage.

    Verbatim wording from the response

    “There is no nationally recognised policy for wide bore nasogastric (Ryles) tubes for aspiration drainage. The existing OUH policy is for nasogastric (NG) tubes when used for feeding. Current practice for insertion of a wide bore tube is based on the Royal Marsden manual of clinical and cancer nursing procedures. Only one of the 9 similar Trusts who we approached has a policy which is virtually identical to the Royal Marsden manual.”

    Source location

    Response from Oxfordshire University Hospitals NHS Foundation Trust
    Page 2 · response
    Published 27 March 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

    Present and publish the Ryles tube policy and communicate it to all staff through a Trust-wide safety message.

    Verbatim wording from the response

    “The Oncology Matron has set up a working group to review current practice, evaluate external resources and produce a Trust wide policy. The policy will set out the Trust standards for managing patients with Ryles Tubes for aspiration drainage. The working group includes nursing and medical staff across the organisation including anaesthetics, surgery, oncology and gastroenterology representatives. The first meeting was held on 3 February 2025. The policy will be presented to the OUH Clinical Policy Group by April 2025 and a Trust wide safety message will be communicated to all staff which will include the link to this policy. The publication of the policy will be followed by training of the appropriate staff through ward-based learning delivered by clinical educators.”

    Source location

    Response from Oxfordshire University Hospitals NHS Foundation Trust
    Page 2 · response
    Published 27 March 2025

    Open published response

  4. Inner North London

    AI-generated summary

    Nimo OSMAN · 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

    Nimo Osman was in state detention under a Hospital Order and receiving psychiatric inpatient care when she collapsed on the ward on 21 April 2022. She was unresponsive for over half an hour before an ambulance was called and died in hospital on 23 April 2022 from hypoxic ischaemic brain injury. The principal concerns were delays in recognising the emergency and calling an ambulance, whether learning had been embedded among staff, completion of venous thromboembolism assessments, and ambiguity in the Trust’s venous thromboembolism policy.

    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

    Ambiguity in the venous thromboembolism policy

    Wider context from the report

    “With regard to the East London NHS Foundation Trust’s policy in relation to Venous Thromboembolism, I noted during the course of the evidence that this appeared to possibly conflict with NICE guidelines in some respects. There also appeared to be aspects of the policy that were ambiguous and open to different interpretations. I was told the policy remains in force and unchanged. The concern here is that possible ambiguity may lead to a non-universal interpretation of the policy, thereby putting patients at risk. ”

    Source location

    Nimo OSMAN · Prevention of Future Deaths report
    Page 4 · 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

    Remove unclear VTE assessment information from the Physical Healthcare Policy and publish an update directing staff to the VTE policy.

    Verbatim wording from the response

    “the Physical Healthcare Policy is not clearly set out. Therefore, the VTE information has been removed from the aforementioned policy in a soon to be published update and it has been made clear that the VTE policy is the appropriate reference. The changes to the Physical Healthcare Policy are expected to be agreed through the Physical Health in Mental Health Committee in November 2024.”

    Source location

    Response from East London Foundation Trust
    Page 5 · response
    Published 13 August 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

    The separate VTE policy is unambiguous and aligned with NICE guidelines, although VTE information in the Physical Healthcare Policy is unclear.

    Verbatim wording from the response

    “13. It has come to my attention that the inquest only considered the VTE assessment information as provided in the Trust’s Physical Healthcare Policy v.14.1, February 2021. The Trust has a more recent and separate Venous Thromboembolism (VTE) Reducing Risk policy v. 3, March 2023. The information in the VTE policy is unambiguous and in-line with NICE guidelines. It is accepted that the VTE assessment information contained in”

    Source location

    Response from East London Foundation Trust
    Page 4 · response
    Published 13 August 2024

    Open published response

  5. Birmingham and Solihull

    AI-generated summary

    Sinon MASHA · 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

    Sinon Masha was born at home on 17 December 2021 following a breech presentation that was not identified until labour. After a 27-minute delay before delivery of his head, he suffered a catastrophic hypoxic brain injury and died on 21 December 2021. The principal concern was that the Trust’s process for managing home births against medical advice was not operating as set out in its guidance, was fragmented, and might result in insufficiently informed birth choices that put lives at risk.

    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 formally plan and consider amendments to birth-choice guidance

    Wider context from the report

    “2. Specifically, Section 5 of the Birth Choices Guidance include: “5.1 All women requesting birth outside of guidance must be referred for discussion to the consultant midwife via BadgerNet for decision-making regarding their birth choices. ... 5.7. Where there are complexities that require the input of other professionals and if the woman remains undecided or voices a decisive choice to pursue a plan outside of Trust guidance a joint multiprofessional appointment must be arranged. 5.8. This appointment should include the consultant midwife; the woman’s named obstetric consultant and other relevant professionals/clinicians as needed. The consultant midwife will convene the multiprofessional team meeting with the purpose of ensuring that a comprehensive multiprofessional pregnancy and birth plan is formulated. 5.9. There may be occasions when the multiprofessional team cannot meet. In these circumstances it is acceptable for the multiprofessional team to see the woman separately. However, the team members must still agree a plan together and document this on the woman’s records.” 3. Evidence given at the inquest pertaining to the current situation was that the system outlined in section 5.8 of the Birth Choices Guidance is not in operation at all. Evidence was given by UHB’s Community Matron that without the input of a Consultant Obstetrician at the multiprofessional appointment, things might be missed in the birth plan, and the information given by the Consultant Midwife and Community Midwives may not carry the same weight with the patient as hearing the opinion of the Consultant Obstetrician. It was stated in evidence by the Community Matron that this could put the lives of Mums and babies at risk. 4. Evidence was given by the Director of Midwifery that although patient’s named Consultants are not involved in multiprofessional appointments with the patient there is a bi-weekly meeting of the other professionals who discuss all high risk patients and then the Consultant midwife meets with the patient’s named Consultant (who will have reviewed the patient in clinic) and discusses the individual cases and the birth plans. This system is felt to be working satisfactorily by the Consultant midwife. 5. I remain concerned that the current approach has evolved from necessity rather than being a carefully considered and planned amendment to the Trust’s guidance. Furthermore, the approach appears fragmented increasing the risk of mis-communication or mis-understanding. This system also deprives the patient of the benefit of hearing the perspectives of all the relevant professionals together in a setting where they, the patient, can witness the discussion and be satisfied that everyone has considered all the relevant factors and answered any queries or concerns they may have relevant to their decision. Consequently, I am concerned that patients may not be making fully informed decisions resulting in birth choices that put lives at risk. ”

    Source location

    Sinon MASHA · 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

    Review and align the Birth Choices and home birth guidelines to clarify referral pathways, team responsibilities, and inclusion in birth-planning discussions.

    Verbatim wording from the response

    “• A review of the Birth Choices Guidelines (CG1200) and the home birth guidance (CG1143) is being undertaken and will be completed by 31 October 2023. Currently there are discrepancies in relation to the referral pathway, roles and responsibilities of members of the multi-professional team (including Consultant Midwife), and inclusion of the woman in birth planning discussions. Alignment of these guidelines will provide a clear and standardised pathway for referral and management for women/birthing people requesting birth outside of guidance including homebirth, and clarity of Roles and responsibilities of each member for the Multi professional team.”

    Source location

    Response from University Hospitals Birmingham NHS Foundation Trust
    Page 2 · response
    Published 7 July 2023

    Open published response

  6. Derby and Derbyshire

    AI-generated summary

    Rachael Chloe WALKER · Prevention of Future Deaths report

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

    Report summary

    Rachael Chloe Walker died in hospital on 19 June 2021 after a placental haemorrhage and amniotic fluid embolism at 37 weeks of pregnancy. The report identified missed opportunities involving the recording and implementation of an earlier delivery plan and national guidance. The principal concern was whether the Trust had sufficiently robust processes for updating clinical guidance and ensuring essential equipment and procedures were in place.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure timely updating and incorporation of clinical policies and guidance

    Wider context from the report

    “My principal concern is that having heard evidence from the Trust as to ‘lessons learnt’ and its current processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, I remain unclear that the Trust now has sufficiently robust processes in place to prevent similarly avoidable deaths to that of Chloe. Indeed, I am unclear that the processes are substantively different to those that existed at the time of Chloe’s death. It was of very particular concern to hear that clinicians at the time were aware of revised national pregnancy guidance issued in September 2018 but this had not been incorporated into Trust policy and guidance. I was told that introducing revised guidance was necessarily complex and lengthy and yet the Trust did incorporate the revised guidance just several weeks following Chloe’s death and it appears because of her death. It was also very concerning to hear that the Trust had established a regional pregnancy service using out of date guidance. Certain changes relating to the circumstances of Chloe’s death have only very recently been addressed or are in process; for example, the procedure to call and respond to a major maternal haemorrhage was to be tested a week or two after the inquest. I therefore consider that the Trust should review its processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, in the interests of preventing future deaths, and that those processes should ensure timely revisions and associated actions. ”

    Source location

    Rachael Chloe WALKER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Manchester City

    AI-generated summary

    Name not published · 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

    A 78-year-old woman developed severe sepsis and necrotising fasciitis following dental treatment. She was not triaged or assessed promptly at hospital, suffered a cardiac arrest, underwent emergency surgery, and died on 6 July 2019. The concerns included the currency and implementation of sepsis protocols, staff training and awareness, and timely recognition and treatment of sepsis.

    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 keep sepsis protocols and policies up to date

    Wider context from the report

    “1. That MFT ensure that all their sepsis protocols and policies are up to date. ”

    Source location

    Name not published · 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

    Update and issue the Trust-wide sepsis policy, aligned with current NICE guidance and incorporating HIVE-related practice changes.

    Verbatim wording from the response

    “MFT has a Trust wide Sepsis Policy (see attached) which was updated on 11 July 2022 and issued to all staff across MFT in September 2022 via the Group Sepsis Committee. The purpose of the policy is to give guidance and define standards of care in relation to the recognition and treatment of patients with sepsis and septic shock in adult patients. The recent updates made were to harmonise the existing MFT policy with the previous policy which had been in place at NMGH. These updates also incorporated changes arising from implementation of MFT’s new Trust wide electronic patient record (HIVE, see below). The policy is in line with current NICE guidance. It will be reviewed in September 2025 or sooner in the event of any significant recommendation to alter practice.”

    Source location

    Response form Manchester University NHS Foundation Trust
    Page 2 · response
    Published 4 October 2022

    Open published response

  8. Cornwall and Isles of Scilly

    AI-generated summary

    Coco Bradford · 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

    Coco Bradford, a 6-year-old girl with autism, developed diarrhoea and vomiting, was diagnosed with haemolytic uraemic syndrome, deteriorated despite treatment and died in Bristol on 31 July 2017. The substantive concerns relate to the size and review of intravenous fluid boluses, when to escalate intensive care, and how clinicians should weigh antibiotic treatment when bacterial gastroenteritis and possible sepsis coexist because antibiotics may worsen haemolytic uraemic syndrome.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to maintain aligned and current guidance on IV fluid bolus volumes for children presenting with shock

    Wider context from the report

    “1) In April 2009, NICE published CG 84 on Diarrhoea and Vomiting caused by gastroenteritis in Under 5s and management. Paragraph 1.3.3 deals with IV fluid management for patients presenting with shock. The guidance suggests rehydration with rapid IV infusion at 20mls/kg. The guidance is now a little dated and it is at odds with the Resuscitation Council UK Guidelines issued in 2021 which provide that for children and infants presenting with shock, fluid should be given in boluses of 10mls/kg – there is an emphasis on smaller boluses with careful re-assessment after each bolus to enable early identification of signs and symptoms of fluid overload. This was particularly relevant in Coco’s treatment where there was concern she may develop HUS with associated compromise of kidney function. As there appears now to be a move towards smaller boluses of fluid with more frequent review, it may be that you will also feel it appropriate to reconsider when to escalate care to colleagues in intensive care i.e. whether it should still be after two boluses or after a particular total amount of fluid. ”

    Source location

    Coco Bradford · 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

    Review relevant NICE guidance for alignment with the 2021 UK Resuscitation Council paediatric advanced life support guidance.

    Verbatim wording from the response

    “Your report, which has been reviewed by our internal patient safety team and chief medical officer, states that the NICE guideline on the diagnosis and management of diarrhoea and vomiting caused by gastroenteritis in under 5s [CG84] is not in line with the UK Resuscitation Council’s 2021 guideline on paediatric advanced life support. Having reviewed the guidance, we agree that the volume of fluid bolus does not align and as a result of this being highlighted, we have also looked at our other guidance of relevance.”

    Source location

    2022-0012-Response-from-NICE_Published
    Page 1 · response
    Published 20 January 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the 2021 UK Resuscitation Council guideline and consider whether CG84 and related NICE guidance need updating.

    Verbatim wording from the response

    “In light of our initial review, your report has now been forwarded to our guideline surveillance team who will review the UK Resuscitation Council’s 2021 guideline and consider if CG84 and other related NICE guidance need to be updated.”

    Source location

    2022-0012-Response-from-NICE_Published
    Page 1 · response
    Published 20 January 2022

    Open published response

  9. North Wales (East and Central)

    AI-generated summary

    Kyle Nicholas James Hurst · 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

    Kyle Nicholas James Hurst was admitted to Glan Clwyd Hospital on 24 January 2021 after taking an undisclosed quantity of a substance and died there later the same day despite treatment. Concerns included the lack of an adopted protocol for accelerated administration of N-Acetylcysteine and delays in implementing procedures intended to mitigate risks from failures to act on diagnostic results.

    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 adopt accelerated N-acetylcysteine administration into a standard operating protocol

    Wider context from the report

    “1. Evidence given at the inquest by the ED Consultant indicated that it has been recognised that the accelerated administration of N-Acetylcysteine may be beneficial in the treatment of a ████████ but this has not yet been adopted into a Standard Operating Protocol despite this having been proposed in August 2021 ”

    Source location

    Kyle Nicholas James Hurst · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. East London

    AI-generated summary

    Mr Paul Sartori · 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 Sartori sought emergency medical assistance for chest pain on 24 October 2019, was directed from A&E to an urgent care centre, diagnosed with costochondritis, and later died at home on 27 October 2019 after becoming unresponsive. A post-mortem examination found a ruptured dissecting aortic aneurysm. The report raised systemic concerns about awareness and diagnosis of aortic dissection in emergency departments, including the adequacy of current guidance and risk-scoring tools.

    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 update streaming guidance in line with relevant learning and guidance

    Wider context from the report

    “1. The Inquest heard evidence that the streaming guidance in place for Barts Health A & E staff and NELFT staff had not been updated to take into account the learning from the death of Mr Sartori and to take into account the guidance from the THINK AORTA Campaign (launched in 2016). ”

    Source location

    Mr Paul Sartori · 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

    Review and submit joint streaming guidance incorporating THINK AORTA learning for governance approval.

    Verbatim wording from the response

    “NELFT and Barts Health have worked closely to review the current streaming guidance and incorporate the learning from the ‘THINK AORTA’ campaign. The guidance was reviewed on 18th May 2021 by Clinical and Operational leads for NELFT and Barts Health. It has now been submitted to the joint governance and operational group for consideration and sign off at the next session on 8th June 2021.”

    Source location

    2021-0123-Response-from-Royal-London-Hospital-Redacted
    Page 2 · response
    Published 29 April 2021

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026