24 Oct 2025 Sophie Louise TOWLE · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Lack of policy prompts for cross-sector consultation in foreign-body cases View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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Sophie Louise TOWLE · 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
Sophie Louise TOWLE died at Kings Mill Hospital on 27 May 2024 after suffering a large pulmonary embolus originating from a deep vein thrombosis in her left leg. The report describes concerns about the management of an inserted foreign object, VTE risk assessment and related policy and training, mental health services for patients with personality disorders, staffing levels, and cross-sector communication and working.
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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 policy prompts for cross-sector consultation in foreign-body cases
Wider context from the report “1. Lack of joint agency policy/cross-sector working between physical and mental health trusts in relation to the insertion of foreign bodies
I heard evidence that it would have been beneficial in Sophie’s case for there to have been an MDT between Sophie’s psychiatric team (NHCT) and her physical health team (Orthopaedics and Anaesthesia at SFH). The reason that this would have been of assistance is due to the complexity of cases where there are physical and mental health considerations in play for decisions around the management of a foreign body.
There is no embedded mechanism for arranging MDT meetings, or indeed for any liaison or contact between these teams, in such cases. Similarly, there is no policy or procedure which prompts clinicians from either team to consider an MDT in these cases or, at the very least, picking up the phone for a consult.
If this had happened in Sophie’s case, it seems likely that the outcome in relation to the management of the foreign body would have been different. Sophie’s psychiatric team were keen for removal and were satisfied that they could implement a robust policy to avoid re-insertion, which was one of the main concerns of the Orthopaedic team.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” Source location Sophie Louise TOWLE · 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 Trial a joint physical and mental health policy for managing patients who insert foreign bodies, including joint meetings and impact review.
Verbatim wording from the response “Staff at Nottinghamshire Healthcare Foundation Trust (NHFT) and Sherwood Forest Hospital Trust (SFHT) have collaborated on creating a joint management policy that provides guidance to staff on the management of patients who have inserted a foreign body. This includes the recommendation of joint meetings to support joined up collaborative care for patients requiring support from both services. This is being trialled for three months, and the impact of its use will be reviewed.” Source location Response from Nottingham Healthcare NHS Foundation Trust
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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 Implement and approve a new guideline for managing deliberately inserted foreign bodies, including clear MDT and mental-health consultation requirements.
Verbatim wording from the response “Upon conclusion of the Inquest, a comprehensive review of the SOP for deliberately inserted foreign bodies, as initially presented to HM Coroner, was undertaken. This review was conducted with the support and oversight of the Governance Support Unit to ensure rigorous examination and improvement of the procedure.” Source location Response from Sherwood Forest Hospitals NHS Foundation Trust
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9 May 2025 Janet Alison Anderson · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of coordinated discharge planning and joint working between trusts View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Greater Manchester Mental Health NHS Foundation Trust Manchester University NHS Foundation Trust NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Manchester University NHS Foundation Trust
Establish an escalation pathway beyond the PTL meeting for delayed Mental Health Services discharges, bringing cases to GMMH senior leadership to support confirmation of hospital discharge dates.
View source
NHS Greater Manchester Integrated Care Board
Implement locality improvement plans addressing accommodation, complex-needs, step-up, step-down, escalation, urgent-care integration and cross-border discharge barriers.
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NHS Greater Manchester Integrated Care Board
Review Multi Agency Discharge Event governance, attendance, decision-making and data capture.
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NHS Greater Manchester Integrated Care Board
Operate a senior system Multi Agency Discharge Event forum to improve clinically ready-for-discharge escalation.
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NHS Greater Manchester Integrated Care Board
Develop a consistent end-to-end brokerage and funding pathway with responsibilities, stage time standards and a protocol for external-provider delays.
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NHS Greater Manchester Integrated Care Board
Provide additional voluntary, community and social-enterprise capacity in Manchester to prevent avoidable admissions and support timely discharge.
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NHS Greater Manchester Integrated Care Board
Roll out system-wide a four-level escalation policy for clinically ready-for-discharge mental-health patients by quarter three.
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Greater Manchester Mental Health NHS Foundation Trust
Conduct a joint internal review of the patient journey through a GMMH learning multidisciplinary meeting with partner agencies.
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Greater Manchester Mental Health NHS Foundation Trust
Establish a full-time Operational Manager for Community Flow to oversee early discharge planning, identify barriers, track actions, and coordinate senior communication with MFT.
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Janet Alison Anderson · Prevention of Future Deaths report
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Report summary
Janet Alison Anderson, who had schizophrenia, Lewy Body Dementia and Parkinsonism symptoms, was admitted to Manchester Royal Infirmary with a suspected infection and remained there after she was medically optimised for discharge. She subsequently declined, developed repeated infections, and died on 28 October 2024 from bilateral pneumonia. Concerns included the prolonged hospital stay, lack of joined-up working and discharge planning between trusts, poor documentation of key decisions, and the resulting unavailability of an acute hospital bed.
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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 coordinated discharge planning and joint working between trusts
Wider context from the report “1. The inquest heard evidence that the prolonged hospital stay and lack of progress in finding a suitable place in the community significantly contributed to her decline.
She had been suitable for discharge from 20th May and there was no clear strategy to progress her discharge or for the two different trusts to work together to ensure a speedy and safe discharge .
The evidence before the inquest indicated a lack of joined up working between the two trusts that meant that despite the clinical concerns about the impact of her prolonged hospital stay she remained in an acute setting
” Source location Janet Alison Anderson · 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 Establish an escalation pathway beyond the PTL meeting for delayed Mental Health Services discharges, bringing cases to GMMH senior leadership to support confirmation of hospital discharge dates.
Verbatim wording from the response “Actions taken by MFT
MFT accept that the established escalation processes through the PTL meeting did not achieve timely discharge for Mrs Anderson. This was largely a result of the specific circumstances of her case, particularly the requirement for her to be accommodated outside her current local authority area. However, as a result of her case, discussions have been held with colleagues in GMMH to provide a more robust escalation process where discharge being organised by the CMHT is taking longer than expected.” Source location Response from Manchester University NHS Foundation Trust
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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 Implement locality improvement plans addressing accommodation, complex-needs, step-up, step-down, escalation, urgent-care integration and cross-border discharge barriers.
Verbatim wording from the response “To support the reduction, NHS GM localities have committed to and submitted Improvement Plans. These show that barriers to discharge remain, particularly in relation to accommodation pathways and individuals with complex needs. Localities are addressing these barriers through focused actions around step-up/step-down provision, targeted escalation approaches for complex patients, urgent and emergency care integration schemes, and coordinated planning for cross-border discharges. Manchester locality remains the locality with the highest number of Out of Area Placements (OAPs), Long Stay Patients (LSP’s), and CRFD cases. However, significant work has been undertaken and, as an example of progress to date, we have seen a 38% reduction in the Manchester locality, giving us confidence that our plans and actions are having an impact.” Source location Response from Greater Manchester Integrated Care
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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 Multi Agency Discharge Event governance, attendance, decision-making and data capture.
Verbatim wording from the response “GMMH have worked closely with NHS GM and Manchester commissioners to understand internal causes of delay, identify resource priorities, and explore immediate opportunities within existing services to reduce flow pressures. This work includes:” Source location Response from Greater Manchester Integrated Care
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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 Operate a senior system Multi Agency Discharge Event forum to improve clinically ready-for-discharge escalation.
Verbatim wording from the response “• Improved CRFD escalation through a newly implemented senior system MADE forum” Source location Response from Greater Manchester Integrated Care
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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 consistent end-to-end brokerage and funding pathway with responsibilities, stage time standards and a protocol for external-provider delays.
Verbatim wording from the response “In addition, a series of extraordinary MADE events have taken place, reviewing every CRFD case and identifying both individual and system-level blockers. One of the key actions agreed is the development of a consistent, end-to-end brokerage and funding pathway. This will define clear responsibilities, time standards at each stage, and introduce a formal protocol for cases that depend on external provider responses. In these cases, delays will be logged and monitored but not attributed to statutory agencies.” Source location Response from Greater Manchester Integrated Care
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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 Provide additional voluntary, community and social-enterprise capacity in Manchester to prevent avoidable admissions and support timely discharge.
Verbatim wording from the response “• Additional Voluntary Community and Social Enterprise (VCSE) capacity in Manchester locality to support prevention of avoidable admissions and ensure timely discharge following inpatient admissions” Source location Response from Greater Manchester Integrated Care
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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 Roll out system-wide a four-level escalation policy for clinically ready-for-discharge mental-health patients by quarter three.
Verbatim wording from the response “As well as the actions and improvements listed above, an escalation policy for Mental Health patients who are CRFD is due to be rolled out system wide by quarter 3. This escalation process could be applied to the case of a patient who is CRFD in a medical bed but waiting for a package of care through a MH provider. The process, which is currently being piloted, provides a system aligned to 4 levels of escalation, levels 1-4. Any case where a mental health patient is CRFD with an unidentified barrier to discharge can be escalated.” Source location Response from Greater Manchester Integrated Care
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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 joint internal review of the patient journey through a GMMH learning multidisciplinary meeting with partner agencies.
Verbatim wording from the response “Both Trusts have agreed to the opportunity to internally review Ms Anderson’s patient journey, GMMH will hold a Learning Multi-Disciplinary Team Meeting, with the following invitees:” Source location Response from Greater Manchester Mental Health
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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 Establish a full-time Operational Manager for Community Flow to oversee early discharge planning, identify barriers, track actions, and coordinate senior communication with MFT.
Verbatim wording from the response “There are internal processes within GMMH which bring all patients who are identified as being ‘clinically ready for discharge’ (CRFD) into daily meetings to track progress in discharge planning and drive plans forward. From May 2024 Ms Anderson’s case and attempts to assess and identify a placement picked up in pace and focus as a result, but this should have been commenced earlier. There should be a focus on identifying barriers to discharge and making discharge planning the focus from the first day of admission; in many instances this is the case but clearly not in the instance of Ms Anderson where this only occurred once hitting CRFD. To rectify this, GMMH has developed a new post in the CMHT’s of a full time Operational Manager for Community Flow who will commence in post on 23 June 2025.” Source location Response from Greater Manchester Mental Health
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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 concern about lack of joint working is disputed because the case was repeatedly discussed at daily meetings involving the relevant organisations.
Verbatim wording from the response “hospital but for whom there are other obstacles to discharge. This meeting is held daily and attended by representatives of the hospital, the Local Care Organisation (also part of MFT) and other relevant stakeholders including GMMH and the local authority.” Source location Response from Manchester University NHS Foundation Trust
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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 Issues specifically relating to the patient’s care will be addressed by Manchester University Hospitals and Greater Manchester Mental Health NHS Foundation Trusts.
Verbatim wording from the response “I note that your report has been shared with Manchester University Hospitals NHS Foundation Trust (MFT) and Greater Manchester Mental Health NHS Foundation Trust (GMMH) and trust they will respond to the issues specifically relating to Ms. Anderson’s care. I have responded to the issues you raise in light of the work undertaken by NHS GM as commissioner responsible for health and social care..” Source location Response from Greater Manchester Integrated Care
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23 Dec 2024 William Charles Hare (Bill) · Prevention of Future Deaths report Essex
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Concerns raised 3
Disjointed inter-hospital coordination delaying treatment progression View source Failures to organise and coordinate inter-hospital transport View source Ineffective interaction between people and systems across Southend and Basildon Hospitals View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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William Charles Hare (Bill) · 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
William Charles Hare (Bill) presented with abdominal and left loin pain in November 2022 and was subsequently diagnosed with metastatic urothelial cancer. He died in a hospice on 23 January 2024 after delays in diagnosis and treatment, including delays in biopsy, specialist review, MDT consideration, hospital transfer and scan results. The report identified systemic and procedural errors and ineffective coordination between Basildon and Southend Hospitals as substantive concerns.
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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 Disjointed inter-hospital coordination delaying treatment progression
Wider context from the report “vi. In his last admission to Basildon Hospital between November 2023 and January 2024 there were delays in progressing his treatment due to the disjointed nature of the inter-relationship between Basildon and Southend Hospitals as well as delays in transporting him to Southend Hospital which included failures to organise transport and properly coordinate his transfer.
” Source location William Charles Hare (Bill) · 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 Failures to organise and coordinate inter-hospital transport
Wider context from the report “vi. In his last admission to Basildon Hospital between November 2023 and January 2024 there were delays in progressing his treatment due to the disjointed nature of the inter-relationship between Basildon and Southend Hospitals as well as delays in transporting him to Southend Hospital which included failures to organise transport and properly coordinate his transfer .
” Source location William Charles Hare (Bill) · 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 Ineffective interaction between people and systems across Southend and Basildon Hospitals
Wider context from the report “ix. The lack of a specialist renal consultant at the MDT and lack of effective interaction between the people and systems at Southend and Basildon Hospitals prevented quick and effective decision making and, therefore, progress of Bill’s diagnosis and treatment.
” Source location William Charles Hare (Bill) · 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 Operate a focused weekly kidney and upper-tract urological cancer MDT reviewing relevant recent scans with specialist multidisciplinary participation across hospital sites.
Verbatim wording from the response “A further key development is the creation of a focused weekly kidney/upper tract urological cancers MDT (multi-disciplinary team) meeting. By separating this MDT from the general pelvic MDT, patients with suspected upper tract urological cancers are reviewed in a very timely manner and it is our routine practice to review all relevant patient scans taken within the past 7 days.” Source location Response from Mid and South Essex NHS Foundation Trust
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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 Use one comprehensive patient-tracking system across hospital sites to monitor cancer pathways, diagnostic reporting, timescales and required escalations.
Verbatim wording from the response “We now have one comprehensive patient tracking system for all hospital sites providing a centralised monitoring for all cancer patients and their progress through the cancer pathway.” Source location Response from Mid and South Essex NHS Foundation Trust
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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 Specialist renal consultant participation and cross-site hybrid MDT working are considered to have addressed concerns about decision-making and hospital interaction.
Verbatim wording from the response “We are confident that these concerns have been addressed by the development of our kidney/upper tract urological cancer specific MDT meetings which take place following the general MDT each week.” Source location Response from Mid and South Essex NHS Foundation Trust
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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 transfer delay did not affect the clinical outcome because appropriate care was provided at Basildon Hospital.
Verbatim wording from the response “We acknowledge that there were issues with inter hospital transfers and delays, however in this case transferring from Basildon to Southend had no bearing on the clinical outcome as Mr Hare was receiving appropriate care in Basildon HDU. However, we appreciate there should have been better communication at this time with the patient and his family. Should a patient require urgent transfer for specific treatment this is prioritised by the Trust and the East of England ambulance service.” Source location Response from Mid and South Essex NHS Foundation Trust
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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 Urgent transfers are prioritised by the Trust and East of England ambulance service.
Verbatim wording from the response “We acknowledge that there were issues with inter hospital transfers and delays, however in this case transferring from Basildon to Southend had no bearing on the clinical outcome as Mr Hare was receiving appropriate care in Basildon HDU. However, we appreciate there should have been better communication at this time with the patient and his family. Should a patient require urgent transfer for specific treatment this is prioritised by the Trust and the East of England ambulance service.” Source location Response from Mid and South Essex NHS Foundation Trust
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Concerns raised 1
Inconsistent coordination between specialist and non-specialist hospitals View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
George Eliot Hospital NHS Trust NHS England The British Transplantation Society UK Kidney Association (UKKA; formerly the Renal Association University Hospitals Coventry and Warwickshire 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. 12
The British Transplantation Society and UK Kidney Association (UKKA; formerly the Renal Association
Collaborate to produce recommendations addressing specialist contact, information sharing, renal care access, responsibility and care-location concerns.
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George Eliot Hospital NHS Trust
Maintain a master copy of local specialist centre contact details for switchboard.
View source
University Hospitals Coventry and Warwickshire NHS Trust
Finalise, agree, and cascade shared guidelines for managing acutely unwell kidney-transplant inpatients.
View source
University Hospitals Coventry and Warwickshire NHS Trust
Provide UHCW renal-team attendance at GEH to review renal inpatients on request, up to twice weekly, under the agreed SLA.
View source
University Hospitals Coventry and Warwickshire NHS Trust
Consider using referapatient.org to document communication between renal departments and other hospitals.
View source
University Hospitals Coventry and Warwickshire NHS Trust
Agree referral indications and referral routes with George Eliot Hospital for specialist renal input.
View source
University Hospitals Coventry and Warwickshire NHS Trust
Provide onsite renal consultant inpatient review at George Eliot Hospital and South Warwickshire Foundation Trust under service-level agreements.
View source
University Hospitals Coventry and Warwickshire NHS Trust
Act as the primary specialist transfer centre for renal patients admitted to peripheral hospitals, regardless of their parent specialist unit.
View source
University Hospitals Coventry and Warwickshire NHS Trust
Develop and share guidance with George Eliot Hospital on CMV sample tubes, urgent turnaround, contacts and escalation.
View source
George Eliot Hospital NHS Trust
Continue liaison with UHCW renal specialists to develop robust joint clinical guidelines.
View source
George Eliot Hospital NHS Trust
Maintain the consultant-to-consultant referral process for renal specialist advice and patient transfers.
View source
George Eliot Hospital NHS Trust
Provide twice-weekly UHCW renal specialist visits for renal patients at GEH under the existing service-level agreement.
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John Frederick Doyle · 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
John Frederick Doyle, a kidney transplant recipient, was admitted with rectal bleeding and a persistent cough and was later diagnosed with a severe cytomegalovirus infection after delays in testing, diagnosis and transfer to specialist care. He deteriorated to multiple organ failure and died on 30 December 2023. Concerns included unclear arrangements for contacting specialist centres, sharing information, accessing renal guidance, initiating transfers and coordinating care between specialist and non-specialist hospitals.
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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 Inconsistent coordination between specialist and non-specialist hospitals
Wider context from the report “Concern 6: Coordination Between Specialist and Non-Specialist Hospitals
There may be variation in how specialist renal hospitals engage with non-specialist hospitals that rely on their expertise , impacting collaborative efforts in patient care. Currently, there is no clear guidance on how specialist and non-specialist teams should work together effectively to ensure consistent, high-quality care for these patients.
” Source location John Frederick Doyle · 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 Collaborate to produce recommendations addressing specialist contact, information sharing, renal care access, responsibility and care-location concerns.
Verbatim wording from the response “Following your email request received on 12th November 2024, the UK Kidney Association (UKKA; formerly the Renal Association) and the British Transplantation Society (BTS) have collaborated and produced the following recommendations in response to your concerns.” Source location Response from UKKA and BTS
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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 Maintain a master copy of local specialist centre contact details for switchboard.
Verbatim wording from the response “1. The first recommendation is ensuring switchboard have a master copy of local specialist centre contact details and the Trust can confirm that this action has been taken.” Source location Response 2 from George Eliot Hospital NHS Trust
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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 Finalise, agree, and cascade shared guidelines for managing acutely unwell kidney-transplant inpatients.
Verbatim wording from the response “As you are aware from the evidence of the medical witnesses at the inquest on 8 November 2024, the renal team at UHCW have been developing guidelines to assist George Eliot Hospital (GEH), a non-renal specialist hospital, in the management of acutely unwell kidney transplant renal inpatients. We are pleased to report that these guidelines have been finalised and agreed between the Trusts and we enclose a copy.” Source location Response 1 from Coventry and Warwickshire Partnership Trust
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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 Provide UHCW renal-team attendance at GEH to review renal inpatients on request, up to twice weekly, under the agreed SLA.
Verbatim wording from the response “In addition, both Trusts have agreed a Service Level Agreement (SLA) which means that a member of UHCW’s renal team will attend GEH and review their renal inpatients on GEH request up to twice a week.” Source location Response 1 from Coventry and Warwickshire Partnership Trust
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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 Consider using referapatient.org to document communication between renal departments and other hospitals.
Verbatim wording from the response “The SLA and guideline set up a clear framework to ensure good communication between the Trusts including timely investigation and treatment. Additionally, processes to document communication between renal department and other hospitals, “referapatient.org” is being considered.” Source location Response 1 from Coventry and Warwickshire Partnership Trust
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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 Agree referral indications and referral routes with George Eliot Hospital for specialist renal input.
Verbatim wording from the response “We confirm that staff at UHCW are aware of internal escalation routes. The escalation of concerns is via the renal registrar and renal consultant. We confirm that UHCW has shared and agreed with George Eliot Hospitals the indications for referral to us as a specialist unit, and the routes for referral.” Source location Response 2 from Coventry and Warwickshire Partnership Trust
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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 Provide onsite renal consultant inpatient review at George Eliot Hospital and South Warwickshire Foundation Trust under service-level agreements.
Verbatim wording from the response “There is an established and effective process for referring patients who are receiving dialysis to their parent unit. UHCW has Service Level Agreements with George Eliot Hospital and with South Warwickshire Foundation Trust that UHCW will provide onsite Renal Consultant Specialist inpatient review at GEH and SWFT upon request up to twice a week. Additionally, UHCW has worked with UK Kidney Association and agreed to be the primary specialist transfer centre for all renal transplant patients admitted from referring hospitals regardless of their parent specialist unit.” Source location Response 2 from Coventry and Warwickshire Partnership Trust
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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 Act as the primary specialist transfer centre for renal patients admitted to peripheral hospitals, regardless of their parent specialist unit.
Verbatim wording from the response “There is an established and effective process for referring patients who are receiving dialysis to their parent unit. UHCW has Service Level Agreements with George Eliot Hospital and with South Warwickshire Foundation Trust that UHCW will provide onsite Renal Consultant Specialist inpatient review at GEH and SWFT upon request up to twice a week. Additionally, UHCW has worked with UK Kidney Association and agreed to be the primary specialist transfer centre for all renal transplant patients admitted from referring hospitals regardless of their parent specialist unit.” Source location Response 2 from Coventry and Warwickshire Partnership Trust
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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 and share guidance with George Eliot Hospital on CMV sample tubes, urgent turnaround, contacts and escalation.
Verbatim wording from the response “Following the sad death of Mr Doyle, UHCW Renal and Virology teams have reviewed processes. Guidelines have been developed which describe: the correct blood tubes, how to ensure urgent turnaround, who to contact, when, and how to escalate to. These have been shared with GEH. Turnaround times for all pathology labs are published in CWPS Handbook V16 May 2024.pdf.” Source location Response 2 from Coventry and Warwickshire Partnership Trust
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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 liaison with UHCW renal specialists to develop robust joint clinical guidelines.
Verbatim wording from the response “1. Contacting Specialist Centres
Following the inquest on 8 November 2024, our Consultant Governance Lead for the Medicine Directorate has continued to liaise with the Consultant Renal Specialist at UHCW to develop robust joint clinical guidelines. GEH will take every case individually as they present and will also contact the appropriate Trust where the patient is receiving their renal care. As well as guidelines from UHCW a laminated quick reference guide has been produced which contains the emergency contact numbers for renal services at UHCW. This will be displayed across the Trust.” Source location Response 1 from George Eliot Hospital NHS Trust
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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 Maintain the consultant-to-consultant referral process for renal specialist advice and patient transfers.
Verbatim wording from the response “Making staff aware of the referral process asking UHCW renal staff to visit a patient on the ward | This is in the guidelines and is a consultant to consultant referral process. The process has been shared as per above.” Source location Response 1 from George Eliot Hospital NHS Trust
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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 Provide twice-weekly UHCW renal specialist visits for renal patients at GEH under the existing service-level agreement.
Verbatim wording from the response “4. Transfer Responsibility
Consultant to consultant clinical conversations will take place if there is a requirement to transfer the patient to the renal centre. There is a Service Level Agreement (SLA) in place for a renal specialist from UHCW to visit renal patients being cared for at a GEH, twice a week. This patient familiarisation will assist in the timely transfer process should the patient need to be relocated to the specialist centre.” Source location Response 1 from George Eliot Hospital NHS Trust
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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 Oversight of delegated renal medicine services rests with individual Integrated Care Boards, including Coventry and Warwickshire ICB.
Verbatim wording from the response “Renal medicine is a specialist service that is delegated to individual Integrated Care Boards. My regional colleagues in the Midlands have been sighted on your Report, and have shared it with Coventry and Warwickshire ICB, for the appropriate oversight.” 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 Providers involved in the care should respond to concerns about local arrangements and processes, rather than NHS England.
Verbatim wording from the response “I note that your Report has also been sent to University Hospitals Coventry and Warwickshire NHS Trust (UHCW) and George Eliot Hospital NHS Trust (GEH). It is appropriate that the providers involved in John’s care respond to the Coroner regarding the concerns raised which relate to local arrangements and process. NHS England has asked to be sighted on their responses once these are in due course and whether any further actions are required from our Specialised Commissioning Teams.” 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 The agreed guidelines, service-level agreement and related processes are considered sufficient to address the six concerns.
Verbatim wording from the response “As you are aware from the evidence of the medical witnesses at the inquest on 8 November 2024, the renal team at UHCW have been developing guidelines to assist George Eliot Hospital (GEH), a non-renal specialist hospital, in the management of acutely unwell kidney transplant renal inpatients. We are pleased to report that these guidelines have been finalised and agreed between the Trusts and we enclose a copy.” Source location Response 1 from Coventry and Warwickshire Partnership Trust
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19 Apr 2024 Dr Richard George Hardman · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of a mechanism for multidisciplinary medical coordination under a single practitioner View source
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AI-generated summary
Dr Richard George Hardman · 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
Dr Richard George Hardman had complex swallowing and respiratory problems associated with prior radiotherapy and Parkinson’s disease. He was admitted to hospital on 7 August 2023 with aspiration pneumonia, and the inquest concluded that he died from aspiration pneumonia arising from natural disease and recognised effects of necessary medical treatment. The principal concern was the absence of a mechanism for coordinating care across different medical disciplines and hospital sites under the leadership of a single practitioner.
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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 a mechanism for multidisciplinary medical coordination under a single practitioner
Wider context from the report “The absence of any obvious mechanism for the various medical disciplines across different hospital sites to be brought together in complex medical cases under the leadership of a single practitioner in a position to evaluate and co-ordinate the best approach and combination of medical care for the patient.
” Source location Dr Richard George Hardman · 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 Continue progressing the appointment of care coordinators for patients with complex medical needs.
Verbatim wording from the response “In terms of the specialist services provided by the North West Ventilation Unit there is a Long-Term Ventilation Service (LTVS). When dealing with patients with complex medical issues, the LTVS provides regular and "ad hoc" urgent nurse-led and consultant-led appointments. Patients have access to a 24h helpline. When their patients are admitted to another hospital, we have a dedicated staff member to provide advice to those care teams. For frail patients we provide home visits. These complex cases are discussed at the weekly multidisciplinary team meeting that are minuted, and we communicate with other services regularly. This service recognises the need to appoint care coordinators for patients with complex medical needs and progress to achieve this continues.” Source location Response from NHS England and GMIC
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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 Processes for managing complex patients across Greater Manchester specialties are better addressed by the Greater Manchester Integrated Care Board.
Verbatim wording from the response “We note that you have also addressed your Report to the Greater Manchester Integrated Care Board (GM ICB) and they are better placed to address your concern regarding processes across the Greater Manchester system for management of patients with complex medical needs, under the care of different specialties. NHS England has however engaged with GM ICB on the concerns raised.” Source location Response from NHS England and GMIC
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7 Dec 2023 Sarah CHAPPELL · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Delays and confusion in inter-hospital transfer coordination View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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Sarah CHAPPELL · 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
Sarah Chappell was transferred to University College London Hospital on 31 May 2023 and died there on 23 June 2023. The report identified concerns about delays in transfer, failure of the appropriate clinical team to take charge, inadequate pain relief and poor communication. It also identified inappropriate management of her nasogastric tube; the inquest concluded that her care was suboptimal and that, if the tube had been managed appropriately, she would have survived this episode.
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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 Delays and confusion in inter-hospital transfer coordination
Wider context from the report “1. There was a ten day delay in Ms Chappell’s transfer from the Princess Royal Hospital to UCLH . I was told that this might have been because of a lack of beds, but it might also have been because of confusion about which UCLH site was the accepting surgeon’s preferred destination , a confusion that was understood at the time by the Princess Royal to be a rejection of the transfer.
” Source location Sarah CHAPPELL · 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 Develop and disseminate a urology referral form documenting transfer reasons, decisions, clinical priority, and coordination-centre notification.
Verbatim wording from the response “Recognising that there was confusion between PRUH and UCLH relating to transfer we will develop a referral form for urology by May 2024 to improve documentation around the reason for transfer and agreed decisions to inform the plan of care. This will be led by the clinical lead for urology and will mirror some of our best practice referrals such as in the thoracic service.” Source location Response from University College London Hospitals
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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 transfer delay reflected unavailable UCLH beds and an unconfirmed referral by PRUH, although UCLH acknowledges confusion about the transfer arrangements.
Verbatim wording from the response “Ms Chappell was transferred to UCLH as an emergency referral from PRUH on 1st June 2023, as the team there believed she had suffered a perforation of her neobladder. She had been discussed by the PRUH team with a urology consultant on 22 May 2023 and accepted for transfer, however there were no available beds at the time at UCLH. PRUH appear to have organised Ms Chappell’s transfer to the UCLH Emergency Department without confirming with the Urology team at UCLH and Ms Chappell was subsequently admitted to a surgical ward (T14 north) when they had a bed available. Ms Chappell was then transferred to T14 Acute Surgical Unit on the evening of 1st June 2023.” Source location Response from University College London Hospitals
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13 Sep 2023 Geoffrey Douglas HOAD · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure of inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Spire Healthcare Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Department of Health and Social Care
Maintain additional ambulance capacity funded to expand capacity and improve response times.
View source
Department of Health and Social Care
Deliver new ambulances and specialist mental health vehicles.
View source
Spire Healthcare Limited
Review all transfers of care from Spire Norwich Hospital to Norfolk and Norwich University Hospital during October 2021–October 2023.
View source
Spire Healthcare Limited
Complete and register a hospital-level risk assessment addressing ambulance transfer delays.
View source
Spire Healthcare Limited
Complete and register a group-wide risk assessment addressing ambulance transfer delays.
View source
Spire Healthcare Limited
Actively explore alternative private ambulance providers for interfacility transfers, assessing their compatibility with emergency response and destination-facility systems.
View source
Spire Healthcare Limited
Join the local Inter Facility Transfer Group to support coordination of unplanned emergency patient transfers.
View source
Spire Healthcare Limited
Continue working with Inter Facility Transfer Group members, including Norfolk and Norwich University Hospital, to mitigate interfacility transfer risks.
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Geoffrey Douglas HOAD · 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
Geoffrey Douglas Hoad underwent a total hip replacement on 3 August 2022 and subsequently developed a paralytic ileus, respiratory compromise and deteriorating renal function. He was transferred to Norfolk and Norwich University Hospital after an ambulance response that took more than 14 hours, and he died on 7 August 2022 after developing cardiac ischaemia and a myocardial infarction. The principal concern was the continuing considerable delays in attending ambulance calls amid very high demand and pressure on the healthcare system.
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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 inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment
Wider context from the report “9. Spire Norwich Hospital does not deal with multi-disciplinary and emergency treatment at its hospital and transfers patients requiring such treatment to local acute Trusts, usually the Norfolk and Norwich University Hospital.
10. Spire Norwich Hospital continues to rely on EEAST to transport such patients to the acute hospital, being fully aware of the demands placed on the EEAST generally and the delays which occur as a result.
11. At the inquest Spire Norwich Hospital placed great reliance on now being part of an Interfacility Transfer Group led by the Norfolk and Norwich University Hospital working with the EEAST to look at a pathway in respect of inter hospital transfers. The evidence of EEAST was that this pathway was not expected to reduce delays in inter hospital transfers.
12. This concern has been raised at previous inquest.
” Source location Geoffrey Douglas HOAD · 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 Maintain additional ambulance capacity funded to expand capacity and improve response times.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
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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 Deliver new ambulances and specialist mental health vehicles.
Verbatim wording from the response “Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
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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 all transfers of care from Spire Norwich Hospital to Norfolk and Norwich University Hospital during October 2021–October 2023.
Verbatim wording from the response “Action 2
Review of all transfers of care from SNH to Norfolk and Norwich Hospital in the period October 2021 to October 2023.” Source location Response from Spire Healthcare
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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 Complete and register a hospital-level risk assessment addressing ambulance transfer delays.
Verbatim wording from the response “24. Spire Healthcare is acutely aware of the demands placed on NHS ambulance services and the resulting delays in ambulance response times.” Source location Response from Spire Healthcare
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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 Complete and register a group-wide risk assessment addressing ambulance transfer delays.
Verbatim wording from the response “26. Spire Healthcare has completed a group wide risk assessment in respect of ambulance transfer delays and this risk is recorded on the national risk register. The risk is regularly reviewed and all actions to reduce the risk are considered and recorded. One such action is to consider the use of private ambulance services to support interfacility transfers. This is addressed in more detail below.” Source location Response from Spire Healthcare
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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 Actively explore alternative private ambulance providers for interfacility transfers, assessing their compatibility with emergency response and destination-facility systems.
Verbatim wording from the response “26. Spire Healthcare has completed a group wide risk assessment in respect of ambulance transfer delays and this risk is recorded on the national risk register. The risk is regularly reviewed and all actions to reduce the risk are considered and recorded. One such action is to consider the use of private ambulance services to support interfacility transfers. This is addressed in more detail below.” Source location Response from Spire Healthcare
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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 Join the local Inter Facility Transfer Group to support coordination of unplanned emergency patient transfers.
Verbatim wording from the response “29. The Inter Facility Transfer Group (IFTG) led by NNUH was set up to facilitate the inter facility transfer of unplanned emergency patients in the local area. Its first meeting took place in June 2022. As at October 2023, the membership of the group comprises representatives from the following organisations:” Source location Response from Spire Healthcare
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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 Inter Facility Transfer Group members, including Norfolk and Norwich University Hospital, to mitigate interfacility transfer risks.
Verbatim wording from the response “31. Following the inquest into the death of Mr Hoad and the subsequent concerns raised by HM Coroner, SNH raised concerns to the chair of the Interfacility Transfer Group that EEAST’s PFD witness had stated in court that the work of the IFTG was not expected to reduce delays in interhospital transfers. The chair of the IFTG met with EEAST’s Head of Patient Safety and it was agreed that, as of 02.10.23, they (EEAST’s PFD witness at the inquest) would join the IFTG in order that they are fully aware of the purpose of the group and involved in all associated actions. The intended benefits of the IFTG are as follows:” Source location Response from Spire Healthcare
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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 Two local private ambulance providers could not contract for transfers because they were subcontracted to EEAST and lacked capacity.
Verbatim wording from the response “26. Spire Healthcare has completed a group wide risk assessment in respect of ambulance transfer delays and this risk is recorded on the national risk register. The risk is regularly reviewed and all actions to reduce the risk are considered and recorded. One such action is to consider the use of private ambulance services to support interfacility transfers. This is addressed in more detail below.” Source location Response from Spire Healthcare
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19 Jul 2023 Carole MCQUINN · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 1
Failure to seek specialist input from the Leeds treating team View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Carole MCQUINN · 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
Carole MCQUINN underwent pancreatic surgery in February 2022 and subsequently experienced pancreatic leakage, abdominal collections and prolonged hospital treatment. After discharge without a discharge note, medication or follow-up appointment, concerns about infection were not adequately recorded or escalated, and a positive swab result was not reviewed until several days later. She was later admitted with suspected intra-abdominal sepsis and was found unresponsive in hospital; the inquest concluded that she died from a pulmonary embolism likely related to post-operative infection, inflammation and immobility.
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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 seek specialist input from the Leeds treating team
Wider context from the report “3. The deceased had an emergency admission to York Hospital on 4/5/22 with suspected intra-abdominal sepsis. A York doctor was verbally tasked with communicating with the surgical team at Leeds to report back on a comparison of CT scans from both hospitals. No record of this contact - which was verbally reported in positive terms - was made by either hospital and no evidence could be provided as to who had spoken to whom and in what terms. Further, despite the lengthy and complex treatment the deceased had undergone in Leeds, and her attendance there the day prior to admission to York, no contact was made by the treating team at York with the treating team at Leeds , to allow for additional specialist input into the deceased's management and consideration of possible transfer of care .
” Source location Carole MCQUINN · 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 Use Patient Pass to coordinate and record referrals, information requests and advice between hospitals and specialist departments.
Verbatim wording from the response “Since this death the AMS CSU has started to use new IT software (Patient Pass) to improve coordination and recording of requests for information and advice. Patient Pass is a two-way messaging tool that is used to facilitate referrals and improve communication between hospitals and specialist departments. It is relied on by a number of specialist teams in LTHT to speed up referrals and support clinical process reliability. It improves record keeping as details of referrals and responses are automatically saved onto patients’ PPM+ records and it also provides the organisation with a full audit trail for information governance purposes.” Source location Response from Leeds Teaching Hospitals NHS Foundation Trust
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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 Contact York surgical colleagues to explain communication arrangements and discuss measures to prevent similar coordination failures.
Verbatim wording from the response “Since the death, and in response to your report, senior members of the team have made contact with colleagues in the surgical team in York to explain the arrangements in place and to discuss the issues raised by this case so that both trusts can work together to avoid similar problems arising in the future.” Source location Response from Leeds Teaching Hospitals NHS Foundation Trust
Open published response
9 Jun 2023 Alice Jean FOX · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 1
Lack of protocols ensuring safe and appropriate multi-party discharge arrangements 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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Alice Jean FOX · 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
Alice Jean FOX, known as Jean, died in hospital on 1 July 2021 from severe infection resulting from bacterial infection of the surgical site following partial hip replacement after a fall. Concerns included her lengthy wait in the discharge lounge and late arrival at rehabilitation, which meant usual admission assessments were not completed, and delays in reviewing blood results and referring her back to hospital despite signs of infection.
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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 protocols ensuring safe and appropriate multi-party discharge arrangements
Wider context from the report “1. Jean had spent a lengthy period in the general hospital discharge lounge, during which time which she would not have had close checks and observations as compared to ward-based care. She did not arrive at the rehabilitation hospital until late at night and so did not have the usual core admission assessments. Such situations appear to me to have the potential to place patients such as Jean at significant risk. Given that there would usually be three parties involved in the transfer (the discharging hospital, the transporting ambulance service, and the discharge destination) there is opportunity for consideration of protocols to ensure such discharge arrangements are safe and appropriate .
” Source location Alice Jean FOX · Prevention of Future Deaths report
Open source report
Concerns raised 1
Lack of a service level agreement for treatment of patients from Cornwall when the UHP service is unavailable View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Anthony James REEDMAN · 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
Anthony James Reedman suffered a basilar artery stroke while at home, but an ambulance delay meant thrombolysis was administered 4.5 hours after the stroke. He died following a further brain haemorrhage after the unsuccessful thrombolysis attempt. The principal concerns were the lack of a 24/7 thrombectomy service for Royal Cornwall Hospital Trust patients and the absence of a service level agreement with the nearest 24/7 service when the local service was unavailable.
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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 a service level agreement for treatment of patients from Cornwall when the UHP service is unavailable
Wider context from the report “(2) The nearest 24/7 thrombectomy service is at NHS North Bristol. However, there is no service level agreement between Southmead and RCHT for the treatment of patients from Cornwall when the UHP service is unavailable . This limits the options available to RCHT clinicians in considering treatment for stroke patients.
” Source location Anthony James REEDMAN · 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 Explore with University Hospitals Plymouth and Royal Cornwall Hospital what interim out-of-region thrombectomy referral support North Bristol can offer.
Verbatim wording from the response “On an interim basis, as University Hospitals Plymouth transition to a 24/7 seven days a week thrombectomy service in October 2023, we will explore with them and RCHT what support North Bristol can offer by way of out of region referrals in an attempt to mitigate the risk of patients that are suitable for thrombectomy procedures not receiving this procedure.” Source location Response from North Bristol NHS Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.