Recurring concern

Unsafe assessment and management of facial fractures

First to latest report 13 Apr 2017 — 8 Sep 2022

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
2

What this concern includes

Includes failures of controls specifically dedicated to assessing, treating or monitoring facial fractures, including recognition of associated bleeding or other complications, appropriate examination, specialist input and selection of suitable treatment.

What is not included
  • Excludes generic physical-examination or diagnostic failures where facial fractures are not materially involved.
  • Excludes general epistaxis management where no facial-fracture context is identified.
  • Excludes unrelated facial injuries, head injuries or trauma-management concerns unless the assertion specifically concerns facial-fracture assessment or treatment.
  • Excludes generic staffing, training, communication or documentation deficiencies unless they directly impair a dedicated facial-fracture control.

Reports and published responses 2 reports

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

  1. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Robert Graham TAYLOR · 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

    Robert Graham Taylor suffered significant facial fractures and a subdural haematoma after a fall, developed epistaxis, then deteriorated and died at Southampton General Hospital on 5 June 2021. The concern was that bleeding following epistaxis or facial fractures may continue in the back of the throat and that the importance of checking this was not widely known in the Emergency Department and Trauma Admission Unit.

    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 awareness of the importance of checking the back of the throat in patients with a history of epistaxis or facial fractures

    Wider context from the report

    “The deceased suffered facial fractures and had episodes of epistaxis. I heard evidence that when a clot forms within the nose the bleeding can continue and is only visible if the back of the patient's throat is looked at. I heard evidence that, in the Emergency Department and Trauma Admission Unit, the importance of checking the back of the throat of a patient with a history of epistaxis or facial fractures was not widely known. ”

    Source location

    Robert Graham TAYLOR · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Disseminate learning to ENT, OMFS and cross-covering senior house officers on recognising continuing anterior or posterior epistaxis after facial trauma and nasal packing.

    Verbatim wording from the response

    “The actions that I support coming out of my discussion with the team is that the clinicians treating such patients would build into their education programme that patients should be explicitly asked to report an unpleasant taste or sensation. Following the meeting I chaired, the following was disseminated to all ENT, OMFS (oral-maxilla facial surgeons) and the cross covering senior house officers.”

    Source location

    Response from University Hospital Southampton NHS Foundation Trust
    Page 2 · response
    Published 5 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Add guidance to surgical senior house officer induction sessions on checking the oropharynx for ongoing posterior bleeding in facial trauma and epistaxis cases.

    Verbatim wording from the response

    “The case was discussed at the ENT M&M meeting on 10th November 2022. The department were content that the management by the SHO was clinically appropriate. It was clearly documented that the posterior bleeding, once identified, stopped after the was pack inserted. It was agreed to raise awareness of epistaxis in facial trauma in OMFS and ED teams managing them. Specific guidance to check the oropharynx in these situations has been added to the surgical SHO induction sessions.”

    Source location

    Response from University Hospital Southampton NHS Foundation Trust
    Page 2 · response
    Published 5 October 2022

    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 Trust disputes that routine oropharyngeal inspection after traumatic epistaxis is clinically valuable or supported by national guidance.

    Verbatim wording from the response

    “We reviewed the national guidance available for the management of epistaxis, currently the only guidance is from NICE (https://cks.nice.org.uk/topics/epistaxis-nosebleeds/management/acute-epistaxis/) this is for when epistaxis have started spontaneously and is not applicable for Traumatic injury such as the case of Mr Taylor. This highlights that there are no national guidelines that suggest the review of the back of a patient throat is advised.”

    Source location

    Response from University Hospital Southampton NHS Foundation Trust
    Page 2 · response
    Published 5 October 2022

    Open published response

  2. Preston and West Lancashire

    AI-generated summary

    Michael John NEWELL · Prevention of Future Deaths report

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

    Report summary

    Michael John Newell died following an admission involving haemorrhage, decompensated liver failure and associated coagulopathy. Concerns included a lack of awareness among emergency and surgical staff of the significance of his liver failure, inadequate recognition and treatment of hypovolaemia, lack of consultant ENT input, weaknesses in the mortality review process, and nursing documentation and management issues.

    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 select treatment appropriate for facial fractures

    Wider context from the report

    “(3) there was a worrying lack by the ENT surgeons to realise the complexity of the case due to the ongoing haemorrhage, decompensated liver failure and associated coagulopathy, that there were no base of skull fractures and to select a method of treatment with Rapid Rhino Pack's that in the view of the ENT expert was only appropriate as a first-line measure and not for facial fractures. Firstly, there was no consultant ENT input into Mr Newell's case at any point prior to his death. Secondly, none of the above issues were brought to the attention of the Court in the ENT consultant's statement raising issues within the Trust for improving patient care. ”

    Source location

    Michael John NEWELL · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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

Back to top

Data last updated 7 September 2026