28 Oct 2024 Susan Patricia SHIPLEY · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 1
Failure to make appropriate ‘fit to sit’ determinations for patients unable to weight bear 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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Susan Patricia SHIPLEY · Prevention of Future Deaths report
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Report summary
Susan Patricia Shipley, who had critical limb ischaemia and previous amputations, fell from a hospital wheelchair while being transferred between hospitals on 28 January 2024 and fractured her right neck of femur. She underwent further amputations, developed pneumonia, and died in hospital on 4 February 2024. The principal concerns were the lack of documented and appropriate “fit to sit” assessments, the decision to transport her in a wheelchair despite her inability to weight bear, and the potential risk of death to others if similar issues recur.
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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 make appropriate ‘fit to sit’ determinations for patients unable to weight bear
Wider context from the report “1. I heard evidence that Yorkshire Ambulance Service (YAS) use ‘fit to sit’ assessments of patients attending Emergency Departments (ED) by ambulance, to determine whether they are fit to sit and wait to be assessed by hospital staff, or need to remain on an ambulance stretcher. ‘Fit to sit’ is thus an important part of YAS’s attempts to reduce handover times for ambulances at acute hospitals. I heard evidence from an ED clinician and a senior YAS paramedic that ‘fit to sit’ assessments should involve a senior practitioner in the ED (such as an ACP or Registrar) going into the waiting ambulance to take a brief history from the patient and undertake a brief physical examination to assess the patient’s ability to sit and wait in a chair for what is likely to be a considerable period of time. This assessment should be recorded and should involve discussion with the Hospital Ambulance Liaison Officer (HALO) deployed by YAS.
2. Mrs Shipley was a right below knee amputee with an ischaemic/gangrenous left foot and a wheelchair user who was unable to weight bear. Despite this, she was deemed ‘fit to sit’, and transported to another hospital, in a hospital issue wheelchair. There was no documentary evidence of any assessment of her fitness to sit made by the paramedics concerned, nor the ACP and HALO who were said to have been involved in it. I found from the evidence of a senior YAS paramedic that any assessment appropriately undertaken could not have concluded that Mrs Shipley was ‘fit to sit’. I found that attempting to transport Mrs Shipley in the hospital wheelchair was inappropriate and resulted in her falling from it and sustaining a fractured neck of femur which contributed to her death.
3. My concerns relate to –
a) The absence of any documentary evidence that an initial ‘fit to sit’ assessment was undertaken involving the parties mentioned above;
b) The decision that Mrs Shipley was ‘fit to sit’ despite being an amputee and unable to weight bear;
c) The absence of any subsequent ‘fit to sit’ assessment being undertaken by the second ambulance crew transporting Mrs Shipley to York, because of an assumption of fitness to sit, and the role of the HALO in this assumption;
d) The absence of evidence that all relevant learning arising from the above has occurred and any actions arising from such learning have been completed, particularly in relation to the first paramedic crew and the HALO;
e) The potential risk of death to others in the event of a recurrence of any of the above.
” Source location Susan Patricia SHIPLEY · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Draft and progress a dedicated fit-to-sit policy through internal review and final clinical governance approval.
Verbatim wording from the response “YAS recognises that the current guidance can be confusing, with the terms ‘fit to sit’ and ‘self-handover’ being used interchangeably between organisation when in fact these are not the same. As such, YAS is currently drafting a ‘fit to sit’ policy, specifically designed to support clinicians in this decision making that links to the existing self-handover process. It will go through internal review at YAS’s Clinical Quality Development Forum before being finally approved for use at YAS’s Clinical Governance Group. It therefore may be subject to amendments dependent on feedback from these groups hence it not being included within this letter. Once formally agreed it will be disseminated across the organisation for use by all clinical staff.” Source location Response from Yorkshire Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the approved fit-to-sit policy across YAS for use by all clinical staff.
Verbatim wording from the response “YAS recognises that the current guidance can be confusing, with the terms ‘fit to sit’ and ‘self-handover’ being used interchangeably between organisation when in fact these are not the same. As such, YAS is currently drafting a ‘fit to sit’ policy, specifically designed to support clinicians in this decision making that links to the existing self-handover process. It will go through internal review at YAS’s Clinical Quality Development Forum before being finally approved for use at YAS’s Clinical Governance Group. It therefore may be subject to amendments dependent on feedback from these groups hence it not being included within this letter. Once formally agreed it will be disseminated across the organisation for use by all clinical staff.” Source location Response from Yorkshire Ambulance Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a Patient Safety Incident Investigation into the moving-and-handling care, including fit-to-sit decisions, handover, diversion, HALO involvement and specialist-hospital transport.
Verbatim wording from the response “Following the conclusion of your inquest, the complexities and potential for learning was discussed at YAS’s Patient Safety Learning Group which is chaired by the Executive Medical Director. From this the commissioning of a full investigation into the care of Mrs Shipley. A Patient Safety Incident Investigation, under the theme of “Moving and Handling” has been initiated, which focuses on identifying learning responses to improve our service to patients. The family of Mrs Shipley have been contacted by letter to ask if they wish to participate in this investigation.” Source location Response from Yorkshire Ambulance Service
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29 Aug 2024 Kasey Beech · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Streaming patients without current chest pain to a MedOCC or equivalent service despite risk of sudden deterioration View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
National Institute for Health and Care Excellence NHS England Royal College of Emergency Medicine
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Royal College of Emergency Medicine
Issue guidance on emergency-department initial assessment and triage.
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Royal College of Emergency Medicine
Collaborate with NHS England to standardise initial-assessment definitions and processes.
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Royal College of Emergency Medicine
Continue working with NHS England to promote standardised initial assessment for emergency-department patients.
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Royal College of Emergency Medicine
Review the effectiveness of current triage systems using evidence.
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Royal College of Emergency Medicine
Help design a new initial-assessment process for implementation across emergency departments in England.
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NHS England
Develop a new initial assessment model collaboratively with emergency care, nursing and patient representatives to improve patient safety.
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NHS England
Introduce the new initial assessment model at sites across England.
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Kasey Beech · Prevention of Future Deaths report
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Report summary
Kasey Beech attended Medway Maritime Hospital with difficulty breathing and chest pain, was directed to a service with a reported three-hour wait, and later suffered a cardiac arrest after her breathing suddenly worsened. She died at St Thomas’ Hospital on 13 October 2021 following treatment. The report raises concerns that the STREAMing model’s focus on current cardiac-sounding chest pain may delay consideration of other immediately life-threatening causes of deterioration, including infective exacerbation of asthma.
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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 Streaming patients without current chest pain to a MedOCC or equivalent service despite risk of sudden deterioration
Wider context from the report “The focus of the current STREAMing guidance regarding the assessment of new non-injury ambulatory patients able to speak in complete sentences without becoming out of breath is on chest pain. The assessment relates to current chest pain and diagnostic investigations are in turn centred on whether there is a cardiac cause. Such patients who do not present with current chest pain are sent to the MedOCC.
However:
(i) pain can fluctuate over time and may not always be concurrent with the initial assessment;
(ii) pain may be masked by analgesia taken prior to assessment; and
(iii) the focus on a cardiac cause itself risks diverting a clinician from the wider question of identifying the cause of the pain. The consideration of differentials that may be immediately life-threatening, or place the patient at risk of a sudden deterioration (e.g. infective exacerbation of asthma) may be delayed, or not given adequate attention as a consequence.
While it is understood that a cardiac issue is high risk and requires prompt diagnosis, and that the exclusion of a cardiac cause causing current chest pain is also diagnostically helpful, I am concerned that the prioritisation of current cardiac-sounding chest-pain and the streaming to a MedOCC/equivalent service may be to the detriment of other patients who are nonetheless at risk of sudden deterioration and therefore creates a risk of future deaths (in both cardiac and non-cardiac patients).
It is understood that the current national guidelines are under review.
” Source location Kasey Beech · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue guidance on emergency-department initial assessment and triage.
Verbatim wording from the response “The Royal College of Emergency Medicine (RCEM) has issued the following guidance regarding the initial assessment (triage) of patients [1]” Source location Response from RCEM
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Collaborate with NHS England to standardise initial-assessment definitions and processes.
Verbatim wording from the response “The RCEM has collaborated with NHS England to standardise the definition and processes that might be used in the initial assessment of a patient attending the emergency department [2]. The RCEM continues to work with NHS England to promote the standardisation of initial assessment of patients presenting to emergency departments. Our current work has involved” Source location Response from RCEM
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NHS England to promote standardised initial assessment for emergency-department patients.
Verbatim wording from the response “The RCEM has collaborated with NHS England to standardise the definition and processes that might be used in the initial assessment of a patient attending the emergency department [2]. The RCEM continues to work with NHS England to promote the standardisation of initial assessment of patients presenting to emergency departments. Our current work has involved” Source location Response from RCEM
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the effectiveness of current triage systems using evidence.
Verbatim wording from the response “The RCEM has collaborated with NHS England to standardise the definition and processes that might be used in the initial assessment of a patient attending the emergency department [2]. The RCEM continues to work with NHS England to promote the standardisation of initial assessment of patients presenting to emergency departments. Our current work has involved” Source location Response from RCEM
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Help design a new initial-assessment process for implementation across emergency departments in England.
Verbatim wording from the response “The RCEM has collaborated with NHS England to standardise the definition and processes that might be used in the initial assessment of a patient attending the emergency department [2]. The RCEM continues to work with NHS England to promote the standardisation of initial assessment of patients presenting to emergency departments. Our current work has involved” Source location Response from RCEM
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a new initial assessment model collaboratively with emergency care, nursing and patient representatives to improve patient safety.
Verbatim wording from the response “NHS England is currently developing a new initial assessment model in collaboration with the Royal College of Emergency Medicine (RCEM), the RCN, the FEN, the Emergency Nurse Consultant Group, and lay (patient) representation. This new model has been successfully introduced in more than 20 sites across England and is specifically focused on improving patient safety. This new model has been successful in bringing down the time to initial assessment to below 15 minutes in sites where it has been implemented.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the new initial assessment model at sites across England.
Verbatim wording from the response “NHS England is currently developing a new initial assessment model in collaboration with the Royal College of Emergency Medicine (RCEM), the RCN, the FEN, the Emergency Nurse Consultant Group, and lay (patient) representation. This new model has been successfully introduced in more than 20 sites across England and is specifically focused on improving patient safety. This new model has been successful in bringing down the time to initial assessment to below 15 minutes in sites where it has been implemented.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Insufficient information about the UTC’s role and STREAMing Model prevents a specific response to concerns about prioritising chest pain.
Verbatim wording from the response “We note the initial assessment took place in an Urgent Treatment Centre (UTC) rather than Emergency Department (ED); from the described circumstances of Ms Beech’s death, it is not clear whether the UTC was effectively ‘gatekeeping’ access to an emergency department or not. Regarding the Simple Triage Rapid Emergency Assessment Method ‘STREAMing Model’ª, we have not been able to find any specific details regarding what appears to be an initial assessment tool, and we do not believe that this is an assessment tool that is routinely used in emergency departments. As a consequence, we are not able to provide any specific response to your concerns regarding the apparent prioritisation of cardiac sounding chest pain over other potentially life-threatening conditions.” Source location Response from RCEM
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The STREAMing pathway does not unduly prioritise cardiac-sounding chest pain, and directing this patient to MedOCC was appropriate after low-risk assessment.
Verbatim wording from the response “Following their review, I am advised by the National Clinical Director that the STREAMing pathway in use by Medway Maritime Hospital does not have an undue prioritisation of chest pain (particularly cardiac-sounding chest pain). As indicated above, the general condition of the patient, any signs of breathlessness, their ability to talk in sentences and their ability to walk unaided are all assessed. In this tragic case, the initial assessments all pointed towards a low-risk situation for which direction to the MedOCC was appropriate. A low risk initial assessment does not completely rule out the possibility of future deterioration but usually indicates the lack of a need for immediate treatment.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Modifying the STREAMing pathway would probably not have predicted the rapid deterioration or altered the initial assessment outcome.
Verbatim wording from the response “In this case, Kasey deteriorated rapidly after leaving the MedOCC. It does not appear that modification of the STREAMing pathway would have been likely to have predicted that or altered the outcome of the initial assessment.” Source location Response from NHS England
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How this respondent position was interpreted
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PFD Monitor interpretation The prioritisation system and acute-care organisation concerns fall outside NICE’s remit.
Verbatim wording from the response “Given that the matters of concern relate to the prioritisation system (STREAMing) which was produced by NHS England, these are not areas that are within NICE’s remit. We believe that the issues raised are best addressed by NHS England, and note that you have also sent your report to them for response.” Source location Response from NICE
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for addressing concerns about its STREAMing prioritisation system.
Verbatim wording from the response “Given that the matters of concern relate to the prioritisation system (STREAMing) which was produced by NHS England, these are not areas that are within NICE’s remit. We believe that the issues raised are best addressed by NHS England, and note that you have also sent your report to them for response.” Source location Response from NICE
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3 Apr 2022 Mandy Jane DICKERSON · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1
Insufficient information gathering during emergency-department streaming to UGPC View source
This report raised 7 other concerns. 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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Mandy Jane DICKERSON · 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
Mandy Jane Dickerson attended the Urgent GP Care Centre on 26 April 2020 after several days of diarrhoea and vomiting, but was discharged without assessment by the medical team. She died at home on 30 April 2020 from sepsis. The principal concerns included a non-mandatory and unreliable sepsis template, inadequate recording and communication of key observations, and confusion about referral responsibilities when specialist assessment was requested.
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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 Insufficient information gathering during emergency-department streaming to UGPC
Wider context from the report “1. I heard detailed evidence of the "streaming" service where patients attending the ED were directed to the UGPC on the basis of very little information gained from their presenting complaint and basic "eyeballing" of the patient . I understood that there is a difference between streaming to UGPC and triage for entry into the ED. I also understood the impact of the pandemic on the provision of services. However, it was apparent that very little documentation of the process with regard to each patient is made, kept or conveyed.
” Source location Mandy Jane DICKERSON · Prevention of Future Deaths report
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28 Apr 2021 Mr Paul Sartori · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to update streaming guidance in line with relevant learning and guidance View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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 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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
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18 Apr 2017 David Lee BIRTWISTLE · Prevention of Future Deaths report Avon
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Concerns raised 2
Failure of front-door ED streaming to include basic physiological measurements View source Lack of integrated front-door ED streaming by primary and secondary care clinicians View source
This report raised 2 other concerns. 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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David Lee BIRTWISTLE · Prevention of Future Deaths report
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Report summary
David Lee Birtwistle died from a pulmonary embolism after being diverted from an accident and emergency assessment two days before his death, meaning further tests were not carried out. Concerns included the absence of NHS 111 referral information for the front door or emergency department and the need for NHS 111 to share information with emergency departments in a user-friendly format.
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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 of front-door ED streaming to include basic physiological measurements
Wider context from the report “1. Streaming of the front door of ED should be an integrated function run by both primary and secondary care clinicians. This should include at least a basic set of physiological measurements.
” Source location David Lee BIRTWISTLE · Prevention of Future Deaths report
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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 Lack of integrated front-door ED streaming by primary and secondary care clinicians
Wider context from the report “1. Streaming of the front door of ED should be an integrated function run by both primary and secondary care clinicians. This should include at least a basic set of physiological measurements.
” Source location David Lee BIRTWISTLE · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.