Recurring concern

Failure to provide timely orthopaedic review

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First reported 28 Oct 2016•Latest report 29 Mar 2018

Definition

What this concern includes

Includes failures to recognise the need for, arrange, escalate or provide timely orthopaedic or Trauma and Orthopaedics review for patients with suspected or confirmed injuries, including missed opportunities for earlier review and failures to organise an orthopaedic assessment.

Not included

  • Excludes specialist review by non-orthopaedic teams unless the assertion explicitly concerns orthopaedic review.
  • Excludes delays in orthopaedic treatment, surgery or transfer after required orthopaedic review has been provided.
  • Excludes generic referral, staffing or communication deficiencies unless they directly cause failure to obtain timely orthopaedic review.
  • Excludes diagnostic or treatment failures where no orthopaedic review was required or identified.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2016–2018

First to latest report issue date

Stated actions
2

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Sandwell and West Birmingham Hospitals NHS Trust1
University Hospitals Sussex NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Black Country

    AI-generated summary

    Mr Frank Hayward · 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 Frank Hayward fell at home on 12 November 2017, sustaining an odontoid peg fracture and subdural haemorrhage, and died on 10 December 2017 after his condition declined. The concerns included failures to correctly assess and diagnose his injuries, delays in Trauma and Orthopaedics review and urgent CT scanning, and poor systems and communication in obtaining a cervical collar.

    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 obtain timely Trauma and Orthopaedics review

    Wider context from the report

    “1. Evidence emerged during the inquest that there were failures to correctly assess and diagnose his injuries in the Emergency Department and there were missed opportunities to have him reviewed by Trauma and Orthopaedics team sooner. ”

    Source location

    Mr Frank Hayward · 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

    Require all clinicians to use the head-injury proforma for hospital falls and Emergency Department presentations.

    Verbatim wording from the response

    “The guideline used by clinicians to inform diagnostic testing and treatment of Head Injuries has been revised in line with the latest National Institute for Excellence (NICE) Clinical Guideline (CG176). Our guideline includes an algorithm of when to image the spine and the head injury proforma now includes a checklist for both head and neck imaging as a further prompt. This proforma was traditionally only used in the Emergency Department (ED), but will now be a requirement for all clinicians to use on any patient who sustains a fall in hospital as well as those who present to the ED. Equally the guideline will apply to anyone who has sustained a head injury, providing consistency with referrals and observations.”

    Source location

    Frank-Hayward-Response
    Page 1 · response
    Published 29 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

    Monitor implementation of the approved head-injury guideline, including imaging, observation duration, specialist referrals and follow-through of requested actions.

    Verbatim wording from the response

    “We will monitor the use of the approved Head Injury guideline following a period of implementation, but in particular we will be ensuring that:”

    Source location

    Frank-Hayward-Response
    Page 2 · response
    Published 29 March 2018

    Open published response

  2. Brighton and Hove

    AI-generated summary

    Leslie Isaac LERNER · 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

    Leslie Isaac Lerner died on 3 June 2016 after treatment for a fractured shoulder, including application of an incorrect sling that caused a deep pressure sore and additional pain. The report identified concerns about inadequate senior review, analgesia, communication, handover, continuity of care, recognition of pneumonia and deterioration, and delay in initiating end-of-life care.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of orthopaedic staff to see the patient

    Wider context from the report

    “16th May 2016 (1) Having been admitted to a renal ward, because of lack of beds elsewhere, a member of the medical staff had a telephone discussion with a member of the Orthopaedic Team and a collar and cuff sling was recommended. This information was not passed onto the Nursing Staff, not properly documented nor was the Patient actually seen by a member of Orthopaedic Team. He should have been seen and a note should have been made. (2) He then was moved to another ward, again not an Orthopaedic Ward, where any chance of correct hand over seems to have been lost because he was transferred to Baily Ward in the middle of the night. No proper handover. There was no referral to physiotherapists and yet the Trusts own paperwork says that exercises should be given by a Physiotherapist and commenced by the patient after seventy two hours of the fracture occurring. No speedy referral to physiotherapists. Within his notes was an utterly inadequate document explaining what the Patient needs to do with a fractured shoulder, however, as the Ward Manager pointed out it does not say what type of sling should be applied for this particular Patient and so she apparently had no idea anything was amiss. This document was not fit for purpose either for the patient or the ward. ”

    Source location

    Leslie Isaac LERNER · 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 organise orthopaedic review

    Wider context from the report

    “15th May 2016 (1) Mr Lerner was back at the RSCH, by ambulance at 1006 hrs in considerable pain and discomfort. He was seen by the Consultant in Elderly Medicine at 1645 and was given analgesia at 1700 hrs – ie almost 7 hours after he arrived at the hospital. This is completely unacceptable, this man was in pain from the fracture and he should have been given pain relief. At that stage he should also have been reviewed by the Orthopaedic Team, no such review was organised. ”

    Source location

    Leslie Isaac LERNER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026