16 Jan 2019 George Foster Thompson · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Insufficient doctor staffing capacity for emergencies, clinical queries and home visits View source
Linked response
Highlands & Trafalgar Square Surgery
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Highlands & Trafalgar Square Surgery
Maintain a protocol requiring home visits requested before closing to be completed after 18:30 when necessary.
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Highlands & Trafalgar Square Surgery
Provide cross-cover through two nearby practices, allowing clinicians to access the practice clinical system remotely during capacity pressures or emergencies.
View source
Highlands & Trafalgar Square Surgery
Deliver group resilience training focused on home visits, emergencies and testing staff knowledge of operational policies.
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Highlands & Trafalgar Square Surgery
Review protocols in light of the concerns raised.
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Highlands & Trafalgar Square Surgery
Arrange telephone triage training for the identified doctor through accredited third-party trainers.
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AI-generated summary
George Foster Thompson · 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
George Foster Thompson, who had multiple chronic health problems and lived in a residential care home, became unwell on 21 August 2018, deteriorated despite receiving antibiotics, and died in hospital on 23 August 2018. The substantive concern was that only one doctor was on duty at the practice, with no resource for a home visit that afternoon even if the doctor considered one indicated.
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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 doctor staffing capacity for emergencies, clinical queries and home visits
Wider context from the report “The evidence before the court was that, on the afternoon of 21st August 2018, there was only one doctor on duty for the practice as a whole . The evidence of the relevant clinician was that in addition to undertaking a (habitually) busy afternoon surgery, he was the only doctor available to deal with emergencies or clinical queries . In those circumstances and whilst the relevant clinician described his telephone call with the care home in terms of being a “triage” consultation, there was no resource in the practice for a home visit to be undertaken that afternoon even if considered indicated by the doctor .
” Source location George Foster Thompson · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a protocol requiring home visits requested before closing to be completed after 18:30 when necessary.
Verbatim wording from the response “3) The doctor in question finished afternoon surgery at 17:20, our surgery closed at 18:30. Attached is our home visit protocol. In devising our home visit protocol, we have taken advice from our LMC (local medical committee). It’s a grey area whether we need to visit patient after we closed at 18:30 and handover to our deputised out of hours service.” Source location 2019-0022-Response-by-H.T-Practice
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide cross-cover through two nearby practices, allowing clinicians to access the practice clinical system remotely during capacity pressures or emergencies.
Verbatim wording from the response “There are two other layers of resilience that are unique to a group practice of our size. We have two other surgeries nearby that can lend support when our capacity is reached or in emergencies when we have staff sickness. Medlock Vale Medical Practice and King Street Medical Centre.” Source location 2019-0022-Response-by-H.T-Practice
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver group resilience training focused on home visits, emergencies and testing staff knowledge of operational policies.
Verbatim wording from the response “We had a group training day on 19th July 2018. The day was dedicated to our group resilience with home visits and emergencies being the centre point of our training. We stress test our resilience and held a quiz to test our staff knowledge of our operational policies.” Source location 2019-0022-Response-by-H.T-Practice
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review protocols in light of the concerns raised.
Verbatim wording from the response “We have reviewed our protocols in light of your letter and we feel that they are robust for the current team that we have in place. We continually review our working practices to reflect changes in work load, winter pressure, staff changes and sickness/emergencies as well as structural and systems failures.” Source location 2019-0022-Response-by-H.T-Practice
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Arrange telephone triage training for the identified doctor through accredited third-party trainers.
Verbatim wording from the response “1) Arrange telephone triage training for the doctor in question. To be arranged by accredited third party trainers.” Source location 2019-0022-Response-by-H.T-Practice
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Three doctors were working on 21 August 2018, contrary to the concern that only one doctor was on duty.
Verbatim wording from the response “1) There was only 1 doctor on duty for the practice as a whole” Source location 2019-0022-Response-by-H.T-Practice
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The afternoon was not habitually busy; the doctor saw nine patients and had six unused appointments, including three afternoon slots.
Verbatim wording from the response “2) The doctor in question stated he has habitually busy afternoon surgeries and was the only doctor to deal with emergencies and clinical queries” Source location 2019-0022-Response-by-H.T-Practice
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Home-visit resources were available: three GPs were available and only two morning visits were requested and completed.
Verbatim wording from the response “3) There was no resources available to deal with home visits on the afternoon of the 21/8/2018.” Source location 2019-0022-Response-by-H.T-Practice
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing home-visit protocols, triage, late-visit practice and cross-cover arrangements were considered sufficient for operational resilience.
Verbatim wording from the response “Regarding home visits. Most of our home visits are phoned through in the morning before 11am. These are shared out among the doctors on that day. All home visits requested are triaged by a GP to assess if the patient needed a home visit. If we conclude that a home visit is needed we will visit the patient. We have never turned down a visit that we felt needed visiting, it’s not in our culture or clinically safe to do so.” Source location 2019-0022-Response-by-H.T-Practice
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28 Nov 2018 Michelle Roach · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Insufficient medical registrar cover at night View source
This report raised 5 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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AI-generated summary
Michelle Roach · 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
Michelle Roach’s inquest was heard at Reading Town Hall between 6 and 9 November 2018, and the narrative conclusion recorded that natural causes contributed to by neglect in her clinical management from 09:11 on 29 January 2014 until 18:07 on 30 January 2014. Concerns related to GP knowledge of venous thromboembolism, record-keeping and reviews of unexpected deaths, as well as the level of overnight medical registrar cover at the hospital trust.
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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 medical registrar cover at night
Wider context from the report “(1) I consider that the trust should review its level of cover by medical registrars at night . Financial constraints and limits on the numbers of medical registrars available to the trust are frequently matters determined outside of the trust’s immediate control, and, as such, these matters may need to be raised outside the trust.
” Source location Michelle Roach · Prevention of Future Deaths report
Open source report
3 Oct 2018 Theresa Maria BUTTON · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1
Insufficient nursing staffing levels for patients with complex needs View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Leeds Teaching Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Leeds Teaching Hospitals NHS Trust
Agree three staffing levels and update ward rosters to reflect current staffing plans.
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Leeds Teaching Hospitals NHS Trust
Review nursing acuity, dependency and skill mix twice yearly and review roster templates against agreed staffing plans.
View source
Leeds Teaching Hospitals NHS Trust
Introduce daily RAG-rated nurse staffing status reporting with escalation of unmitigated ward staffing concerns.
View source
Leeds Teaching Hospitals NHS Trust
Update the Trust-wide shortfall response document to reflect National Quality Board safe-staffing guidance.
View source
Leeds Teaching Hospitals NHS Trust
Continue recruiting registered nurses, midwives and operating department practitioners to increase staffing capacity.
View source See 2 more actions
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AI-generated summary
Theresa Maria BUTTON · 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
Theresa Maria BUTTON underwent a liver transplant, remained in hospital for approximately 15 weeks, suffered multiple complications including a stroke, developed pneumonia, and died on 7 December 2017. Concerns included staffing levels and whether limited nursing capacity affected implementation of treatment plans, nutritional care, communication with family members, and contemporaneous record-keeping.
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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 nursing staffing levels for patients with complex needs
Wider context from the report “1. The staffing levels on Ward J83 should be reviewed , notwithstanding that they currently meet the minimum levels prescribed. The ward handles a challenging cohort of patients with liver disease who have complex needs which merit close nursing attention .
” Source location Theresa Maria BUTTON · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree three staffing levels and update ward rosters to reflect current staffing plans.
Verbatim wording from the response “By way of background, following discussions with senior nursing staff, three levels of staffing for their areas has been agreed and staffing rosters have been submitted to reflect the current staffing level. The three levels are:” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review nursing acuity, dependency and skill mix twice yearly and review roster templates against agreed staffing plans.
Verbatim wording from the response “A twice yearly ward staffing review of nursing acuity and dependency levels is undertaken, which informs changes to skill-mix required and the annual updates to the roster system. Following the July 2018 establishment and skill mix review, 102 roster templates have been reviewed to ensure they align to the current staffing level plan agreed for each ward.” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce daily RAG-rated nurse staffing status reporting with escalation of unmitigated ward staffing concerns.
Verbatim wording from the response “The Trust has in place a comprehensive escalation process to support CSUs in the event of staffing shortfalls and concerns. Further to a pilot in surgical services a RAG rated nurse staffing status report has been introduced for daily reporting. This daily oversight is provided by the Deputy Chief Nurse/Director of Nursing (Operations) with any unmitigated concerns regarding individual ward areas being escalated to the Chief Nurse. A weekly Red, Amber, Green (RAG) status report is provided to the quality meeting and the Executive Director meeting.” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Trust-wide shortfall response document to reflect National Quality Board safe-staffing guidance.
Verbatim wording from the response “This is supported by a Trust-wide document - Actions to be taken when the numbers of Nurses and Midwives per shift falls Short of the Agreed Roster Template. This document was updated earlier in 2018 to reflect and meet the National Quality Board Guidance issued in February 2018. A copy of this is attached for your information.” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue recruiting registered nurses, midwives and operating department practitioners to increase staffing capacity.
Verbatim wording from the response “The Trust continues to recruit band 5 registered nurses, midwives and operating department practitioners with 304 external registered and 5 staff starting in post since April 2018. 262 of the 304 new starters commenced in post in September and October 2018, in line with university out turns. Corresponding to our recruitment figures is a reduction in both registered and unregistered nursing and midwifery vacancies across the organisation. Registered Nurse vacancies have reduced from 14% in September 2018 to 11% in October 2018, with unregistered vacancies reducing from 6% in September to 4% in October 2018.” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Daily staffing reviews, safe-staffing systems and escalation processes are considered sufficient to manage staffing levels and patient-specific needs.
Verbatim wording from the response “Staffing levels on all of our ward areas including ward J83 are reviewed daily in accordance with safe staffing requirements together with the numbers and individual needs of our patients.” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
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19 Sep 2018 Hubert Kelly · Prevention of Future Deaths report Black Country
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Concerns raised 1
Absence of permanent medically qualified staff in the waiting area View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Hubert Kelly · 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
Hubert Kelly was taken to hospital on the evening of 13 November 2017 after his health deteriorated and waited for four hours in a wheelchair in the emergency department with his family. Nursing staff later found that he had died, and concerns included patients waiting in corridors without meaningful interaction or permanent medically qualified staff, with waits of up to seven hours for clinical assessment.
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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 Absence of permanent medically qualified staff in the waiting area
Wider context from the report “1. Evidence emerged during the inquest that following triage assessment nursing staff lacked room or resources to allow patients to remain in the ambulance triage area or in a cubicle and consequently patients were left to wait in corridors;
2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area ;
3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally, with patients waiting to be seen by clinicians for up to seven hours.
” Source location Hubert Kelly · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an Emergency Department escalation plan and an in-reach process.
Verbatim wording from the response “The Trust has implemented an escalation plan and a process of in-reach with ED and increased physician presence. We attached a weekly return which documents the impact of this and” Source location Hubert-Kelly-Response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase physician presence in the Emergency Department.
Verbatim wording from the response “The Trust has implemented an escalation plan and a process of in-reach with ED and increased physician presence. We attached a weekly return which documents the impact of this and” Source location Hubert-Kelly-Response
Open published response
21 Aug 2018 Kiarah Faith Adora Allen · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Insufficient nursing and clinical staffing for very sick babies View source
Linked response
Birmingham Women'S and Children'S NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Birmingham Women'S and Children'S NHS Foundation Trust
Allocate nurses to specific babies on every shift and reinforce the allocation process through staff communications.
View source
Birmingham Women'S and Children'S NHS Foundation Trust
Implement the neonatal workforce plan and continue recruitment to restore staffing capacity.
View source
Birmingham Women'S and Children'S NHS Foundation Trust
Reconstruct and align the NICU e-roster with the workforce plan.
View source
Birmingham Women'S and Children'S NHS Foundation Trust
Move babies where possible to support the safest care, while embedding the practice fully.
View source
Birmingham Women'S and Children'S NHS Foundation Trust
Price the Vocera system for staff to summon colleague support.
View source See 2 more actions
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AI-generated summary
Kiarah Faith Adora Allen · 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
Kiarah Faith Adora Allen was born extremely prematurely and died after an inadvertent total parenteral nutrition fluid overload during a change of treatment, which led to severe metabolic complications and cardiac failure. The report identified unsafe staffing levels, failure to follow the correct procedure, and failure to learn from a previous similar incident. The principal concern was that staffing levels were insufficient when the neonatal unit was full.
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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 nursing and clinical staffing for very sick babies
Wider context from the report “1. I heard evidence in the inquest that at the time this incident occurred there were unsafe levels of nursing and clinical staff . The funding provided for nurses assumed the unit was only 85% full. Therefore when the unit was full, there were insufficient numbers of nurses and doctors . Consideration needs to be given to providing additional funding to enable the unit to be appropriately staffed for the very sick babies they care for.
” Source location Kiarah Faith Adora Allen · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allocate nurses to specific babies on every shift and reinforce the allocation process through staff communications.
Verbatim wording from the response “• Action 2: Nurses are allocated to specific babies each shift.
o The nurse in charge (NIC) is allocating babies to nurse every shift. This is being reinforced through the staff weekly newsletter.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the neonatal workforce plan and continue recruitment to restore staffing capacity.
Verbatim wording from the response “• Action 5: A new workforce plan will be developed by the senior leadership in neonates.
o The workforce plan is live, but recovery through increased recruitment is on-going.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reconstruct and align the NICU e-roster with the workforce plan.
Verbatim wording from the response “• Action 24: Head of Nursing to complete and implement a NICU workforce plan.
o The Workforce plan is being implemented and the NICU e-roster has been reconstructed and aligned to the workforce plan.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Move babies where possible to support the safest care, while embedding the practice fully.
Verbatim wording from the response “• Action 9: Previous shift NIC to review babies and move them where necessary.
o Within current practice, the NIC is moving babies where ever possible to permit the safest possible care, however this is not yet fully embedded.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Price the Vocera system for staff to summon colleague support.
Verbatim wording from the response “• Action 13: Head of Nursing to price the vocera system for staff to be able to summon support from colleagues, if required.
o Pricing for Vocera for all clinical areas is a current on-going task.” Source location 2018-0253-Response-by-Birmimgham-Womanss-and-Childrens-NHS-Trust
Open published response
Concerns raised 1
Insufficient A&E Doctor staffing to cover patient needs View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Shrewsbury and Telford Hospital NHS Trust
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AI-generated summary
Patricia Violet PALIN · 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
Patricia Violet PALIN died on 2 October 2017 after presenting to hospital with sepsis and kidney damage. The report describes delayed recognition and treatment, including delayed antibiotics, absence of oxygen administration, failure to remove leg dressings for examination, and failure to follow sepsis guidelines. Concerns also included limited access to GP records, insufficient A&E doctor cover, and an unavailable prescribed antibiotic.
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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 A&E Doctor staffing to cover patient needs
Wider context from the report “2. During the evening of the 1st October 2017, there were only two A&E Doctors on duty (a third had telephoned in sick ). Too few Doctors were therefore on duty in general to cover patient needs and there did not seem to be in place a programme for trying to get a third Doctor to replace the Doctor who had telephoned in sick.
” Source location Patricia Violet PALIN · Prevention of Future Deaths report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Short-notice Emergency Department staffing gaps cannot always be covered because of workforce fragility and limited available doctors and agency staff.
Verbatim wording from the response “The Trust does have a process in place for trying to backfill vacant shifts in the Emergency Department. At the first instance we will attempt to contact our own doctors via the Departmental Consultants or Medical Staffing representative making contact. We will also advertise via external agencies at the same time to ensure that every attempt is made to fill the gap. I attach a copy of the flow charts used to backfill vacant shifts.” Source location 2018-0183-Response-by-Shrewsbury-and-Telford-Hospitals-NHS-Trust
Open published response
20 Mar 2018 Peter O’Donnell · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Insufficient post-operative medical staffing capacity View source
This report raised 8 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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AI-generated summary
Peter O’Donnell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter O’Donnell was admitted for an elective right total hip replacement and later developed a chest infection and deteriorated. The report identifies concerns about ineffective communication, irregular observations, inadequate documentation, delayed antibiotics, missed opportunities to escalate care, unclear consultant and junior doctor arrangements, and the absence of transfer protocols for unwell patients. It also raises concerns about private hospitals’ reporting requirements and the reporting of nurses’ retrospective additions to clinical records.
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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 post-operative medical staffing capacity
Wider context from the report “2. A single Junior Doctor (Resident Medical Officer) was the sole Clinician providing post-operative care for patients . He was on duty 24/7 and asserted that a daily review of each patient would be adequate (although this would be a minimum and would depend on the condition of the individual patient). Both the monitoring and appraisal of each RMO remained with an outside Employment Agency rather than the private hospital in which they were based. Responsibility for training was similarly unclear.
” Source location Peter O’Donnell · Prevention of Future Deaths report
Open source report
26 Jan 2018 Mrs. Riaz Begum · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Insufficient radiology staffing capacity for CT-guided drainage procedures 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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AI-generated summary
Mrs. Riaz Begum · 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. Riaz Begum developed a bile leak and sepsis following a laparoscopic cholecystectomy, and later developed acute pancreatitis after an ERCP to repair the leak. She died on 16 July 2017 despite treatment for sepsis and multi-organ failure. Concerns included delays in CT-guided drainage and ERCP, insufficient radiology capacity, inadequate escalation, and the potential impact of consultant leave on ERCP availability.
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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 radiology staffing capacity for CT-guided drainage procedures
Wider context from the report “(1) I am concerned that on the 3rd July 2017, a CT Scan indicated the need for fluid drainage to take place under CT guidance. Despite this procedure being deemed necessary, it was not done until the 5th July 2017. The evidence I have heard causes me concern that there were insufficient radiologists/ radiological nurses available to carry out the procedure .
(2) I am also concerned that after the 3rd July the need for the drainage to take place was not adequately escalated to Radiology management when ████████ indicated he could not undertake the procedure within the timescale requested. When the matter was escalated on the 5th July, ████████ had to be essentially told to do the procedure and offered an additional professional fee. I consider that the lack of availability of suitable capacity for undertaking a drainage procedure in the case of someone being treated for sepsis and possible bile leak puts at risk.
” Source location Mrs. Riaz Begum · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to provide continuous junior doctor or registrar cover for NICU View source
This report raised 10 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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AI-generated summary
Owen Richard Widlake · 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
Owen Widlake was born full term and healthy but aspirated meconium and developed worsening respiratory failure. He died at Southampton General Hospital on 31 May 2016 after late diagnosis of persistent pulmonary hypertension of the newborn and an acute intraventricular haemorrhage. Concerns included staffing and medical cover, recognition and escalation of respiratory distress, observation records, staff training, transfer arrangements, and handovers.
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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 provide continuous junior doctor or registrar cover for NICU
Wider context from the report “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU.
(1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift .
(1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff.
2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph.
3) The nursing staff do not appear able to escalate concerns either
i) due to lack of clear care plans and escalation markers
ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN
ii) a lack of empowerment indicating a lack of leadership.
4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves.
5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this.
6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm.
7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover.
” Source location Owen Richard Widlake · Prevention of Future Deaths report
Open source report
19 Oct 2017 June Evelyn Evans · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure to staff wards at correct staffing levels View source
This report raised 3 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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AI-generated summary
June Evelyn Evans · 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
June Evelyn Evans was admitted to St Peter’s Hospital with diarrhoea and was assessed as being at high risk of pressure sores. She developed a severe hospital-acquired pressure sore that became infected, and she died of sepsis on 1 July 2016. The principal concerns were failures to prevent and promptly refer and treat the pressure sore, inadequate nutrition, clinicians’ delayed awareness of the sore, and understaffing across the wards.
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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 staff wards at correct staffing levels
Wider context from the report “4. Mrs Evans was nursed on 3 wards from the 4th to the 30th June. The wards were not staffed according to the levels identified as correct staffing levels by the hospital which detracted from the ability of the nursing staff to undertake the tasks required to protect Mrs Evans from pressure sores and ensure she received adequate nourishment .
” Source location June Evelyn Evans · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.