Recurring concern

Inadequate patient information for surgical procedures

First to latest report 12 Mar 2015 — 24 Sep 2019

Reports that mention this concern
4
Times this concern has been raised
5
Stated actions linked to this concern
9

What this concern includes

Includes failures of patient-facing information arrangements specifically for surgical procedures, including absent, incomplete, unsuitable or undistributed procedure-specific information leaflets and equivalent written or accessible materials about preparation, risks, recovery or required follow-up.

What is not included
  • Excludes generic patient communication or health-literacy deficiencies not specifically tied to information for a surgical procedure.
  • Excludes failures in obtaining informed consent where the consent process, rather than provision of surgical patient information, is the unsafe condition.
  • Excludes discharge information unrelated to surgery, and clinical information exchanged solely between professionals.
  • Excludes failures involving one particular leaflet's wording or format when no broader deficiency in surgical patient-information provision is identified.

Reports and published responses 4 reports

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

  1. Inner South London

    AI-generated summary

    Mr Francis Hodge · 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 Francis Hodge died on 16 November 2018 at University Hospital Lewisham from a perforated colon, seven days after elective laparoscopic repair of multiple incisional hernias. Concerns were raised that he received inadequate discharge advice and was not told to seek help for breathlessness or persistent pain. It was also reported that no patient information leaflet existed for this type of surgery.

    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 patient information leaflet for this type of surgery

    Wider context from the report

    “(4) I was also told that no patient information leaflet existed for this type of surgery as it was not a common type of procedure. ”

    Source location

    Mr Francis Hodge · 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

    Remind preoperative assessment staff to provide the appropriate patient information leaflet and document that provision.

    Verbatim wording from the response

    “The Trust has commenced a communication exercise to remind staff in preoperative assessment to ensure that the appropriate information leaflet is handed to patients and to document that this has been done. An audit of the provision of these leaflets will be completed by December 2019 to ensure that the communication strategy has been effective.”

    Source location

    2019-0338-Response-by-Lewisham-and-Greenwich-NHS-Trust
    Page 2 · response
    Published 10 November 2019

    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

    Complete an audit of patient-information leaflet provision to assess whether the communication strategy was effective.

    Verbatim wording from the response

    “The Trust has commenced a communication exercise to remind staff in preoperative assessment to ensure that the appropriate information leaflet is handed to patients and to document that this has been done. An audit of the provision of these leaflets will be completed by December 2019 to ensure that the communication strategy has been effective.”

    Source location

    2019-0338-Response-by-Lewisham-and-Greenwich-NHS-Trust
    Page 2 · response
    Published 10 November 2019

    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

    Include the availability of patient information leaflets in induction programmes for newly appointed medical staff, emphasising provision during consultations.

    Verbatim wording from the response

    “These information leaflets are available online and their availability is going to be included in the induction programmes of newly appointed medical staff with an emphasis on providing these leaflets during consultation.”

    Source location

    2019-0338-Response-by-Lewisham-and-Greenwich-NHS-Trust
    Page 2 · response
    Published 10 November 2019

    Open published response

  2. West Yorkshire (Western)

    AI-generated summary

    Michael Christopher Hopkins · 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 Christopher Hopkins sustained a right patella fracture requiring surgery and was discharged from hospital. He later collapsed at home and died from a pulmonary thromboembolism, and the report raised a concern about information given at discharge to patients at risk of thromboembolism after surgery for trauma.

    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 discharge information addresses thromboembolism risk after trauma-related surgery

    Wider context from the report

    “To review current practice guidelines with respect to the information provided to patients on discharge from hospital that may be at risk of the formation of thromboembolisms given they have had recent surgery after sustaining a trauma. ”

    Source location

    Michael Christopher Hopkins · 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 patient information provided after blood-clot risk assessment.

    Verbatim wording from the response

    “The Foundation Trust has been working hard to ensure that all eligible patients receive an assessment of their risk of developing blood clots, and can demonstrate consistent compliance with the relevant key performance indicators. Since the Regulation Report was received, we have reviewed the information provided to all patients (not just those who have experienced a trauma), following that assessment of risk, and as a result, the Trust has developed a revised leaflet that all patients will receive. I have attached an example of the leaflet to this letter, and confirm this leaflet will be introduced from the 1st December 2018.”

    Source location

    2018-0331-Response-by-Bradford-Teaching-Hospital-NHS-Trust
    Page 1 · response
    Published 1 March 2019

    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 revised leaflet for patients following blood-clot risk assessment.

    Verbatim wording from the response

    “The Foundation Trust has been working hard to ensure that all eligible patients receive an assessment of their risk of developing blood clots, and can demonstrate consistent compliance with the relevant key performance indicators. Since the Regulation Report was received, we have reviewed the information provided to all patients (not just those who have experienced a trauma), following that assessment of risk, and as a result, the Trust has developed a revised leaflet that all patients will receive. I have attached an example of the leaflet to this letter, and confirm this leaflet will be introduced from the 1st December 2018.”

    Source location

    2018-0331-Response-by-Bradford-Teaching-Hospital-NHS-Trust
    Page 1 · response
    Published 1 March 2019

    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

    Introduce the revised leaflet for all patients from 1 December 2018.

    Verbatim wording from the response

    “The Foundation Trust has been working hard to ensure that all eligible patients receive an assessment of their risk of developing blood clots, and can demonstrate consistent compliance with the relevant key performance indicators. Since the Regulation Report was received, we have reviewed the information provided to all patients (not just those who have experienced a trauma), following that assessment of risk, and as a result, the Trust has developed a revised leaflet that all patients will receive. I have attached an example of the leaflet to this letter, and confirm this leaflet will be introduced from the 1st December 2018.”

    Source location

    2018-0331-Response-by-Bradford-Teaching-Hospital-NHS-Trust
    Page 1 · response
    Published 1 March 2019

    Open published response

  3. Brighton and Hove

    AI-generated summary

    Barry John TUCKER · 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

    The supplied text does not describe the circumstances of Barry John TUCKER’s death beyond recording that an inquest took place. Concerns included lack of pre-operative preparation and senior clinical input, absent enhanced-recovery support and information, inadequate hospital notes, flawed ambulance recall arrangements, and no coherent discharge-planning protocol for enhanced-recovery urology procedures.

    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 provide enhanced recovery paperwork

    Wider context from the report

    “(3) The Enhanced Recovery Nurse Specialist was also away during his admission. He never met her or received any paperwork from her ”

    Source location

    Barry John TUCKER · Prevention of Future Deaths report
    Page 2 · 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

    Failure to provide the enhanced recovery cystectomy leaflet

    Wider context from the report

    “(4) He never received a copy of the leaflet “Enhanced Recovery after having a Cystectomy”. ”

    Source location

    Barry John TUCKER · 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 circulate updated cystectomy pathway documentation covering enhanced recovery, patient information and discharge requirements.

    Verbatim wording from the response

    “Trust Response There is a care pathway document for Cystectomy patients which contains detailed discharge planning information, including prompts and checks which assist in documenting the key stages of the post-operative period and plan of care. That care pathway documentation was not used and the nursing and medical notes do not contain a great deal of detail of Mr Tucker’s post-operative progress. The Trust acknowledges the learning opportunity presented here and has implemented the action plan below.”

    Source location

    2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
    Page 5 · response
    Published 8 March 2018

    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

    Use the cystectomy pathway documentation for all relevant surgical cases.

    Verbatim wording from the response

    “Recommendation: The Cystectomy Pathway patient documentation must be updated and used for all surgical cases no matter what ward to include the latest Cystectomy Enhanced Recovery Preparation Event and Recovery Pathway (CEPER) guidance and ensure clear to what patient information is provided and when (with sign off to state completed) and the discharge process/requirements;”

    Source location

    2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
    Page 5 · response
    Published 8 March 2018

    Open published response

  4. Norfolk

    AI-generated summary

    NICOLA ANNE TWEEDY · 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

    Mrs Tweedy underwent elective varicose vein surgery as a day-case patient on 27 March 2014 and was found collapsed and died at home on 29 March 2014. The inquest recorded pulmonary embolism following recent varicose vein surgery. Concerns included incomplete thromboprophylaxis risk assessment, missing procedure and aftercare leaflets, and incomplete discharge checks and documentation.

    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 provide procedure and aftercare leaflets to patients

    Wider context from the report

    “Specific leaflets relating to the procedure and aftercare were not handed to the patient. It is understood a “tick box” has now been added to documentation recording that this is done. This will only work if forms are properly and timely completed – see below. It is understood training and auditing of forms is now in place, but it is not clear how this is being carried out. ”

    Source location

    NICOLA ANNE TWEEDY · 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

    Document leaflet provision using a pre-assessment tick box and required staff entries.

    Verbatim wording from the response

    “This has not however documented in the past, we have now required our staff to document that they have given standard information to each patient—in order to avoid excessive paperwork.”

    Source location

    2015-0095-Response-by-Norfolk-Norwich-University-Hospitals
    Page 2 · response
    Published 12 March 2015

    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’s implemented Action Plan was considered to have addressed the reported care concerns, with learning and improvement demonstrated.

    Verbatim wording from the response

    “I note that you have sent your report to the Norfolk and Norwich University Hospital NHS Foundation Trust. My officials have liaised with the Foundation Trust about your report and I understand that it has fully considered and responded to each of your concerns relating to the care of Mrs Tweedy. I can report that a recent independent external inspection found that the Foundation Trust had implemented an Action Plan, to address the issues raised by this case, and that this demonstrated that learning and improvement had taken place.”

    Source location

    2015-0095-Response-by-Department-of-Health
    Page 1 · response
    Published 12 March 2015

    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 Department cannot become involved in or comment on individual cases.

    Verbatim wording from the response

    “health and well-being of the public. The Department cannot get involved with or comment on individual cases.”

    Source location

    2015-0095-Response-by-Department-of-Health
    Page 3 · response
    Published 12 March 2015

    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