Concerns raised 1
Failure to transmit relevant medical microbiology information to the accepting transplant centre View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
NHS Blood and Transplant
Develop and implement an electronic system for specialist nurses to record and transmit donor data to transplant centres.
View source
NHS Blood and Transplant
Continue reminding specialist nurses to capture and provide key donor information accurately and fully during the interim period.
View source
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AI-generated summary
Robert James Stuart and Darren Llewellyn Hughes · 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
Robert James Stuart and Darren Llewellyn Hughes developed meningoencephalitis after receiving kidney transplants from the same donor and died on 17 and 19 December 2013 respectively. The infection was caused by a Halicephalobus nematode in the transplanted kidneys. Concerns included incomplete transmission of donor information, inadequate use of the EOS system and the need for a more multidisciplinary organ-acceptance process.
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× 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 transmit relevant medical microbiology information to the accepting transplant centre
Wider context from the report “(2) There was information available on the medical microbiology report which was not passed on to the accepting transplant centre.
” Source location Robert James Stuart and Darren Llewellyn Hughes · Prevention of Future Deaths report
Open source 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 Develop and implement an electronic system for specialist nurses to record and transmit donor data to transplant centres.
Verbatim wording from the response “The NHSBT Board, at its January meeting, approved expenditure to change the way in which Specialist Nurses record and transmit data electronically to transplant centres. This will simplify the work of the nurses, reduce the risk of errors in recording the data in NHSBT systems and increase the amount of data transmitted to transplant centres via EOS. This is a major IT development and we” Source location 2014-0549-Response-by-NHS-Blood-Transport
Open published 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 Continue reminding specialist nurses to capture and provide key donor information accurately and fully during the interim period.
Verbatim wording from the response “expect it to be fully operational by April 2016. In the interim period, we continue to remind the nurses of the importance of capturing and providing key information accurately and fully.” Source location 2014-0549-Response-by-NHS-Blood-Transport
Open published response
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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 microbiology results were unavailable before the transplant decision and therefore could not have affected the decision to transplant.
Verbatim wording from the response “2) Microbiology results
Your observations regarding the microbiology report are noted however NHSBT has obtained written confirmation from the independent testing reference laboratory that although the first blood sample taken at the donor hospital on 25th November 2013 was received for testing the same day, the enterovirus, parechovirus, HSV and VZV results were not available until 3rd January 2014. Additional tests of meningococcal and pneumococcal were requested as additional tests on the 2nd January 2014.” Source location 2014-0549-Response-by-NHS-Blood-Transport
Open published response
27 Nov 2014 Freda Virginia Owens · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 1
Failure to communicate clinical assessment information between relevant specialist teams View source
This report raised 4 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
Freda Virginia Owens · 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
Freda Virginia Owens, aged 93, died after developing bronchopneumonia associated with an infected necrotic pressure ulcer of the left hip, alongside burns and scalds sustained on 2 November 2012. The report identified concerns about the gathering and exchange of information between care and medical professionals, delays in recognising the pressure ulcer, and the resulting delay in treatment.
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× 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 communicate clinical assessment information between relevant specialist teams
Wider context from the report “I now write to the two Hospital Trusts and to the Croft House Rest Home to confirm that in my view action should be taken because there is a concern about the quality of the gathering and exchange of information between the various medical professionals involved in Mrs. Owens’s care for the following reasons:
1. A District Nurse was unaware of potentially important information as regards the Patient including how restricted her movement was.
2. Having considered all of the oral evidence in court and the clinical records, the amount and quality of the information provided to the hospital is limited and this had an impact upon later decisions taken and not least by the Tissue Viability Nurse once she was involved.
3. Although the District Nurse explained why she did not examine the Deceased’s left hip area on 21st November 2012, the Nurse in my view ought to have examined that area given the Patient was viewed as being at high risk of developing pressure areas. Such examination may have prompted her, given her professional experience, to recognise a pressure area as distinct from a burn / scald and that information may then have been communicated on to hospital staff who would have then most likely involved the Tissue Viability Nurse more quickly reducing the chances of an incorrect assumption being made that the hip area was problematic as a result of a pressure area and not due to burns inflicted on 2nd November 2012. However, having chosen not to do so this was not then communicated to other medical professionals involved in her care for them to assess.
4. That following arrival and assessment at the Royal Preston Hospital, that there was a lack of communication between the clinical team and the plastic surgery team , which appears to have contributed to the fact that it was not until 3rd December 2012 when the Tissue Viability Nurse became involved.
These issues as regards the gathering and exchange of information as regards this Patient raise concerns that an incorrect assumption – such as the one made that Mrs Owens hip area was damaged due to the incident involving the commode on 2nd November 2012 - may arise in a future case and with fatal consequences if such an incorrect assumption were not to be recognised early enough to positively affect a Patient’s outcome.
” Source location Freda Virginia Owens · Prevention of Future Deaths report
Open source report
17 Oct 2014 Kirsty Lisa Pritchard · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1
Failure to report post-discharge patient contact to the responsible consultant in a timely manner 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
Kirsty Lisa Pritchard · 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
Kirsty Lisa Pritchard had complex medical needs and a history of self-harm and suicidal ideation. After being discharged from hospital, she contacted the community team several times reporting thoughts of self-harm and suicide; she was later found deceased at home, hanging with a belt around her neck, and was pronounced deceased at 14:15 on 20 January 2013. The report raised concerns about delayed communication of worsening symptoms and risk to the responsible consultant, and deficiencies in systems for contacting and locating her after an immediate risk was reported.
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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 report post-discharge patient contact to the responsible consultant in a timely manner
Wider context from the report “(1)The Root cause analysis report by the Black Country Partnership NHS Trust confirmed that there were issues in relation to the communication of information. Specifically, the evidence presented at the inquest confirmed that CHTT contact with Ms Pritchard following discharge were not reported back to the inpatient Consultant in charge for review and assessment of risk of self harm in a timely fashion .
” Source location Kirsty Lisa Pritchard · Prevention of Future Deaths report
Open source 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 Recirculate the medical escalation flow chart to CHITT and inpatient staff to clarify escalation routes for risk concerns.
Verbatim wording from the response “• The communication with consultants to raise any concerns has been reinforced by recirculating the medical escalation flow chart (Appendix 1) to all CHITT and inpatient staff both clinical and non-clinical so that it is clear which individual any concerns about risk should be raised with.” Source location 2014-0565-Response-by-Black-County-NHS-Trust_Redacted
Open published response
29 Aug 2014 Stephen James Morris · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2
Failure to exchange sufficient relevant mental health information during cross-area transitions View source Failure to confirm mental-health treatment information with the responsible hospital care team before prescribing medication View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
MDU Services Limited
Request written confirmation from the Consultant Psychiatrist or Community Nurse Practitioner for future prescription changes.
View source
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AI-generated summary
Stephen James Morris · 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
Stephen James Morris, who had previously been diagnosed with bipolar affective disorder, was found deceased in the bath at his flat on the morning after 16 June 2013. A post-mortem found high levels of mood-stabilising and antidepressant medication, whose combined effects proved fatal; the inquest concluded that he took his own life. The principal concerns were that Mirtazapine was prescribed despite awareness of his diagnosis and its suitability concerns, based on the patient's verbal account rather than confirmation from the mental health team.
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× 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 exchange sufficient relevant mental health information during cross-area transitions
Wider context from the report “Having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because:
• I am concerned that there was a limited exchange of information as regards Stephen and his mental health between the mental health professionals in Cheshire and their counterparts in Blackpool.
• By the time that Stephen came to Blackpool for what turned out to be the final time the professionals in Blackpool did not have a detailed picture of how Stephen had presented during recent weeks in relation to his mental health.
• When individuals with a similar mental health history as Stephen do move from one area of the country to another there is the potential for a mental health team to find themselves with less detailed relevant information than may be the case for a similar individual who has recently been residing within the immediate area. I am concerned that the quality of exchange of information needs to be such that when mental health professionals find themselves dealing with such an individual that they have as much relevant information as possible to be able to assess the risk such a patient poses and to respond accordingly .
” Source location Stephen James Morris · Prevention of Future Deaths report
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 confirm mental-health treatment information with the responsible hospital care team before prescribing medication
Wider context from the report “Having concluded this inquest, I now write to you to confirm that in my view you should take action because:
• I am concerned that medication was prescribed to a Patient you knew had previously been referred to the local hospital Trust in respect of his mental health and the diagnosis that had been made.
• That you prescribed the medication on the basis of verbal information provided by the Patient rather than seeking some confirmation from those within the Hospital Trust with responsibility for the Patient's mental health care provision.
• That knowing the diagnosis, you prescribed medication you acknowledged was not the preferred medication for this Patient's condition and seemingly in the absence of discussion with those who had responsibility for the Patient’s mental health care.
I would therefore be obliged if the Trust would write to me in due course to confirm what steps if any you propose to take to address these concerns.
” Source location Stephen James Morris · Prevention of Future Deaths report
Open source 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 Request written confirmation from the Consultant Psychiatrist or Community Nurse Practitioner for future prescription changes.
Verbatim wording from the response “This is incorrect. It is clear from the GP records and ████████ evidence that following his consultation, he telephoned ████████ office and verified the position as to the recommendations made by the Community Nurse Practitioner. ████████ however confirms that it is his standard practice to verify information from the patients as to medication changes and he did so in this case by telephoning ████████ office. From an administration perspective, ████████ will ensure that he in future requests that the Consultant Psychiatrist or Community Nurse Practitioner confirm any change of prescription in writing. Given that the patient was deemed to require that medication, it would have been inappropriate for ████████ to have deferred issuing the prescription pending the receipt of written confirmation.” Source location 2014-0522-Response-by-MDU-Services-Limited
Open published response
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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 prescription was not based solely on verbal patient information; the relevant hospital office was contacted to verify recommendations.
Verbatim wording from the response “This is incorrect. It is clear from the GP records and ████████ evidence that following his consultation, he telephoned ████████ office and verified the position as to the recommendations made by the Community Nurse Practitioner. ████████ however confirms that it is his standard practice to verify information from the patients as to medication changes and he did so in this case by telephoning ████████ office. From an administration perspective, ████████ will ensure that he in future requests that the Consultant Psychiatrist or Community Nurse Practitioner confirm any change of prescription in writing. Given that the patient was deemed to require that medication, it would have been inappropriate for ████████ to have deferred issuing the prescription pending the receipt of written confirmation.” Source location 2014-0522-Response-by-MDU-Services-Limited
Open published response
Concerns raised 1
Failure to send discharge summaries to patients’ GPs 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
Martin Rowland HILL · 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
Martin Rowland HILL died on 24 April 2014 after an abdominal x-ray taken during an A&E attendance showed small bowel obstruction, but the report was not seen by subsequent doctors and he was treated for constipation. The concerns included the failure to act on the radiology report, which might have led to surgical review and readmission, as well as medication not being provided on discharge and no discharge summary being sent to his GP.
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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 send discharge summaries to patients’ GPs
Wider context from the report “(6) For completeness, and it is an issue which arose in an earlier Inquest, no discharge summary was sent to the patient’s GP . This appears to have been an exception to normal practice and an indication was given at the Inquest that this issue has already been addressed. Confirmation of this is sought.
” Source location Martin Rowland HILL · Prevention of Future Deaths report
Open source report
20 Jun 2014 Redmond Johnson · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Failure to obtain relevant medical information for care planning during initial reception assessment View source
This report raised 6 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
Redmond Johnson · 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
Redmond Johnson, aged 67, suffered a cardio-respiratory arrest while being transferred to Ipswich Crown Court on 25 November 2011 and died after transfer to Ipswich Hospital. The report identified concerns about the assessment of his fitness for transfer, including a record stating that he had no known medical risks despite the healthcare professional not having seen him. It also identified concerns about the management and documentation of his complex healthcare needs in custody, including liaison with community providers, specialist appointments, investigations, medication and care monitoring.
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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 obtain relevant medical information for care planning during initial reception assessment
Wider context from the report “(1) If a detainee has a history of significant medical problems, healthcare professionals undertaking the initial reception assessment should request further information from the General Practitioner and, where necessary, hospital doctors normally involved in the detainee’s care to enable appropriate care planning while that detainee is in the custody of the prison service.
” Source location Redmond Johnson · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure of two-way communication about prescribing between primary and secondary care View source
This report raised 1 other concern. 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
Denise Sharon Parramore · 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
Denise Sharon Parramore, who had a lengthy history of mental ill health and previous self-harm, died from respiratory depression after taking Tramadol in excess of the prescribed level in combination with other medication. The concerns were that psychiatric services were unaware of the Tramadol prescription and that primary and secondary care should have open two-way communication and access to each other's documentation.
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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 two-way communication about prescribing between primary and secondary care
Wider context from the report “(1) The Psychiatric Services, and in particular her Consultant Psychiatrist, was not aware, prior to Denise Parramore's death, of her being prescribed Tramadol by her General Practitioner. Concerns would have been raised, and action likely taken, if she had been aware. The Consultant Psychiatrist was not informed either by Mrs Parramore herself, nor the General Practitioner of the prescribing of the Tramadol. My concern is that there should be open, and constant two-way communication between those in primary care and secondary care such as in these circumstances.
” Source location Denise Sharon Parramore · Prevention of Future Deaths report
Open source report
22 Apr 2014 Tanya Rosemary Marion Oladejo · Prevention of Future Deaths report West London
View report summary
Concerns raised 1
Failure to communicate medication changes between the GP practice and responsible clinician View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Central and North West London NHS Foundation Trust NHS Hillingdon Clinical Commissioning Group
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
NHS Hillingdon Clinical Commissioning Group
Review processes for recording medications across different healthcare sectors.
View source
NHS Hillingdon Clinical Commissioning Group
Review processes for communicating medication information between healthcare sectors, including medication changes and treatment follow-up.
View source
NHS Hillingdon Clinical Commissioning Group
Discuss with CNWL and Hillingdon Hospitals pharmacy leads the possibility of developing a standard cross-sector medication letter or form.
View source
NHS Hillingdon Clinical Commissioning Group
Have practice pharmacists review and improve medicines-reconciliation processes in GP practices.
View source
Central and North West London NHS Foundation Trust
Circulate an anonymised Clinical Risk Alert highlighting communication lessons from the case to staff across the organisation.
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AI-generated summary
Tanya Rosemary Marion Oladejo · 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
Tanya Rosemary Marion Oladejo was found collapsed and unresponsive on her bed after a friend had not heard from her for approximately one week; police confirmed there were no suspicious circumstances. The inquest concluded misadventure, with the medical cause of death recorded as amitriptyline intoxication. The principal concern was inadequate communication between the GP practice and the responsible clinician about medication, including unilateral changes to amitriptyline prescribing that were not communicated to the responsible clinician.
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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 communicate medication changes between the GP practice and responsible clinician
Wider context from the report “(1) The responsible clinician had made adjustments to the prescribed medication regime including allowing the GP to vary the amount of sertraline according to the patient’s presentation.
(2) The GP, in fact, also on occasion titrated the amount of amitriptyline prescribed according to the patient’s presentation.
(3) The responsible clinician was not made aware of the unilateral titration of amitriptyline so, accordingly, was unaware that a drug she had (in discussion with the patient) prescribed to be used as a sleeping draft was, in fact, being prescribed clearly labelled to be taken in the mornings.
(4) In this case, there was a worrying lack of adequate communication between the GP practice and the responsible clinician about medication prescribed to assist in controlling Tanya’s condition
” Source location Tanya Rosemary Marion Oladejo · Prevention of Future Deaths report
Open source 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 Review processes for recording medications across different healthcare sectors.
Verbatim wording from the response “1. Review the current processes for recording medications in the different sectors by August 2014” Source location 2014-0203-Response-by-Hillingdon-Commissioning-Group
Open published 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 Review processes for communicating medication information between healthcare sectors, including medication changes and treatment follow-up.
Verbatim wording from the response “On receiving the Initial Management Report a view was sought from the HCCG mental health commissioner, the clinical leads for NWL Mental Health Programme Board, and Hillingdon CCG medicines management lead on 19th May. It was agreed to explore the time frame and process for notification of any change of medication and follow-up sessions of treatment between GPs and CNWL lead clinician. A response from the HCCG Head of Medicines Management was received on 27th May 2014.” Source location 2014-0203-Response-by-Hillingdon-Commissioning-Group
Open published 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 Discuss with CNWL and Hillingdon Hospitals pharmacy leads the possibility of developing a standard cross-sector medication letter or form.
Verbatim wording from the response “3. Discuss with the Pharmacy Leads in CNWL and the Hillingdon Hospitals Trust the possibility of developing one standard letter or form for use across all sectors in July 2014” Source location 2014-0203-Response-by-Hillingdon-Commissioning-Group
Open published 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 Have practice pharmacists review and improve medicines-reconciliation processes in GP practices.
Verbatim wording from the response “4. Ensure our practice pharmacists review and improve medicines reconciliation processes in practices starting in July 2014 and on-going thereafter.” Source location 2014-0203-Response-by-Hillingdon-Commissioning-Group
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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 Circulate an anonymised Clinical Risk Alert highlighting communication lessons from the case to staff across the organisation.
Verbatim wording from the response “I must advise you that in our view the issue of particular concern in this case was one that related to inadequate communication by the GP to our clinician and it is appropriate for the CCG to respond to you on that particular point. We are satisfied that in this case our communication systems were effective. However, as an organisation we are always keen to learn from any incidents that occur and we felt it would be helpful to ensure that staff across our organisation are reminded of the importance of good communication. One of the means we have for disseminating such lessons is a Clinical Risk Alert. We will be circulating an alert in the next few weeks which will include reference to this case (in an anonymised form). I should be happy to forward a copy to you if you would find that of interest.” Source location 2014-0203-Response-by-Central-North-West-London-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 The CCG should respond to concerns about inadequate communication by the GP with the Trust clinician.
Verbatim wording from the response “I must advise you that in our view the issue of particular concern in this case was one that related to inadequate communication by the GP to our clinician and it is appropriate for the CCG to respond to you on that particular point. We are satisfied that in this case our communication systems were effective. However, as an organisation we are always keen to learn from any incidents that occur and we felt it would be helpful to ensure that staff across our organisation are reminded of the importance of good communication. One of the means we have for disseminating such lessons is a Clinical Risk Alert. We will be circulating an alert in the next few weeks which will include reference to this case (in an anonymised form). I should be happy to forward a copy to you if you would find that of interest.” Source location 2014-0203-Response-by-Central-North-West-London-NHS-Trust
Open published response
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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 Trust considered its communication systems effective in this case and did not identify a need to change them.
Verbatim wording from the response “I must advise you that in our view the issue of particular concern in this case was one that related to inadequate communication by the GP to our clinician and it is appropriate for the CCG to respond to you on that particular point. We are satisfied that in this case our communication systems were effective. However, as an organisation we are always keen to learn from any incidents that occur and we felt it would be helpful to ensure that staff across our organisation are reminded of the importance of good communication. One of the means we have for disseminating such lessons is a Clinical Risk Alert. We will be circulating an alert in the next few weeks which will include reference to this case (in an anonymised form). I should be happy to forward a copy to you if you would find that of interest.” Source location 2014-0203-Response-by-Central-North-West-London-NHS-Trust
Open published response
8 Apr 2014 Audrey Lily Kelly · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to provide out-of-hours and hospital emergency department clinicians with direct access to patients’ GP notes View source
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AI-generated summary
Audrey Lily 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
Audrey Lily Kelly complained of abdominal pain on 17 November 2013, was prescribed Trimethoprim by an out-of-hours doctor who could not access her GP medical notes, and was found deceased at home two days later. The investigation concluded that she died from natural causes. The principal concern was that out-of-hours services and hospital emergency departments could not access patients’ GP notes, including allergy information, which was considered a serious procedural lapse that could put lives at risk.
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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 out-of-hours and hospital emergency department clinicians with direct access to patients’ GP notes
Wider context from the report “During the course of the evidence it was made very clear to me by the attending doctor who prescribed the medication and also by the nurse who took the call at the Out of Hours service that they could not /are not allowed to obtain and see the electronic notes held by the patient's own GP . This fact was backed up by a senior administrator of the Out of Hours service who reiterated that neither they nor the hospital Emergency Departments, have direct access to GP Notes .
It seems to me that this is a serious lapse in the procedures and will inevitably lead to further lives being lost when, if the notes were available, those lives might be saved.
In the case of the Out of Hours service it seems particularly absurd that these notes are not available when in fact the Out of Hours doctor is deputising for that very GP who
not allowing access to the notes.
It would appear therefore that there is an immediate need for directions to be issued to ALL OUT OF HOURS PROVIDERS and the appropriate Clinical Commissioning Groups to the effect that there must be free and unfettered access to ALL the GP notes in these circumstances.
” Source location Audrey Lily Kelly · Prevention of Future Deaths report
Open source 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 Seek formal assurance from Mastercall on new-starter processes and contingencies for practitioners without NHS Smartcards.
Verbatim wording from the response “Stockport CCG is already engaged in continual improvement work in this area. However, as a result of this investigation, the CCG is also planning the following measures:” Source location 2014-0155-Response-by-Department-of-Health2
Open published 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 Map and analyse shared-record access processes and systems with Mastercall to identify and mitigate further risks.
Verbatim wording from the response “Stockport CCG is already engaged in continual improvement work in this area. However, as a result of this investigation, the CCG is also planning the following measures:” Source location 2014-0155-Response-by-Department-of-Health2
Open published 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 Work with Mastercall to provide fit-for-purpose mobile access to relevant patient information at the point of care through a governed improvement project.
Verbatim wording from the response “Stockport CCG is already engaged in continual improvement work in this area. However, as a result of this investigation, the CCG is also planning the following measures:” Source location 2014-0155-Response-by-Department-of-Health2
Open published response
3 Apr 2014 Graham Harold WATTS · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1
Failure to communicate discharge information to receiving care providers and family View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Sussex 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. 4
University Hospitals Sussex NHS Foundation Trust
Provide ward nurses with refresher training on discharge processes, required documentation and Do Not Attempt Cardio-pulmonary Resuscitation forms.
View source
University Hospitals Sussex NHS Foundation Trust
Emphasize completion of nurse-to-nurse discharge summaries for patients transferred to or returning to residential or nursing home care.
View source
University Hospitals Sussex NHS Foundation Trust
Conduct monthly snapshot audits of ward medical records to monitor discharge-documentation standards.
View source
University Hospitals Sussex NHS Foundation Trust
Develop new discharge-planning paperwork to facilitate timely documentation and daily consideration of patients’ progress toward discharge.
View source See 1 more action
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AI-generated summary
Graham Harold WATTS · 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
Graham Harold Watts was discharged from Princess Royal Hospital to his nursing home, where he arrived hypothermic, hypotensive, oedematous and sleepy. The report raised concerns about a flawed discharge process, blank paperwork and a lack of communication with the nursing home and his son. It also recorded evidence that, had he not fractured his hip in a fall, he would not have died when he did.
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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 communicate discharge information to receiving care providers and family
Wider context from the report “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge.
(2) The discharge paperwork was effectively blank.
(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy.
(4) It is acknowledged and accepted that a change of environment increases the risks of fall.
” Source location Graham Harold WATTS · Prevention of Future Deaths report
Open source 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 Provide ward nurses with refresher training on discharge processes, required documentation and Do Not Attempt Cardio-pulmonary Resuscitation forms.
Verbatim wording from the response “The ward nurses have all had refresher training on the processes they are expected to go through, including but not limited to the related documentation, before any patient is discharged from the ward. This has included a reminder of the correct procedure to be followed with any “Do Not Attempt Cardio-pulmonary Resuscitation” form. The Trust deeply regrets that this form did not accompany Mr Watts on his discharge as it should have done.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Open published 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 Emphasize completion of nurse-to-nurse discharge summaries for patients transferred to or returning to residential or nursing home care.
Verbatim wording from the response “The senior nursing staff agree that it is essential that a nurse to nurse discharge summary is completed for any patient leaving the hospital to go to, or return to, residential or nursing home care. They have emphasized the importance of this to the ward nurses. As part of the programme for developing the skills of junior nurses, the ward is placing increased emphasis on shadowing senior colleagues, to equip these junior staff with the skills needed to make robust decisions and to give them role models to assist with their communication skills.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Open published 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 Conduct monthly snapshot audits of ward medical records to monitor discharge-documentation standards.
Verbatim wording from the response “Each month a snapshot audit is being done of 10 sets of medical records from the ward to ensure that they reflect an acceptable standard of discharge documentation. For this ward, the April review of discharge documentation showed 100% compliance with the requirement for documentation in the discharge planner, and also on the provision of information about discharge plans to relatives.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Open published 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 Develop new discharge-planning paperwork to facilitate timely documentation and daily consideration of patients’ progress toward discharge.
Verbatim wording from the response “The Trust has reviewed the forms currently used for discharge planning and is devising new paperwork which is intended to facilitate timely documentation, and to encourage daily consideration of each in-patient’s progress towards discharge.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Open published response
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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 discharge process was not fundamentally flawed; shortcomings arose from inadequate implementation on this occasion.
Verbatim wording from the response “The Trust acknowledges and apologises that there were significant shortcomings in the discharge planning process for Mr Watts, arising from failures by staff to complete thoroughly all the steps necessary to ensure safe and timely discharge for each patient. The Trust does not accept that the process itself was deeply flawed, but acknowledges that it was not implemented adequately on this occasion.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.