Concerns raised 3
Failure to quarantine relevant medical equipment promptly after clinical events View source Failure to download accurate clinical data from medical devices promptly View source Failure to retain relevant clinical material after clinical events View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Strengthen incident-reporting, device-quarantine and evidence-retention policies through governance ratification and publication.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026. View source
Action
Develop, approve and disseminate SOPs specifying device security, data preservation, storage, testing and manufacturer engagement after device safety events.
Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 August 2026. View source
Action
Produce and distribute clinical-area visual aids prompting immediate evidence-preservation actions and sources of support.
Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 August 2026. View source
Action
Develop and deliver Trust-wide multiprofessional training on prompt reporting, candour, device quarantine, data preservation and related safety processes.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026. View source
Action
Review opportunities to reduce reliance on non-networked devices and improve immediate access to device information.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026. View source
Action
Audit evidence-retention practices one year after policy launch.
Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 August 2026. View source See 3 more actions
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AI-generated summary
Jennifer Susan BIRCH · 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
Jennifer Susan Birch died on 11 April 2025 after suffering anaphylaxis to teicoplanin during the peri-operative period of an elective procedure, resulting in hypoxic brain injury. Concerns included failure to make a 2222 call during the anaesthetic emergency, failures to promptly record and retain evidence after the event, and the absence of a penicillin allergy de-labelling pathway at the Trust.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to quarantine relevant medical equipment promptly after clinical events
Wider context from the report “1. (NUH) Failure to ensure an “inquiring mind” in satisfying the duty of candour
The Trust can only seek to learn lessons from events if it has, at every level, an inquiring mind that seeks to capture all relevant evidence at the earliest opportunity following clinical events.
My investigation, and that of the PSII, was hampered by the failure of staff to complete a Datix report on the day of the event. This led to a failure to quarantine the medical equipment used in theatre (which was suspected of potential malfunction), a failure to download all accurate clinical data from the machines, and a failure to retain the second, retrospectively completed, anaesthetic chart.
This is not an isolated incident, nor one that is unique to this Department. This is a Trust wide issue. Coronial investigations over recent years have been hampered in establishing the truth because of a failure by the Trust to retain relevant material post clinical events (placentas disposed of following neonatal harm – PFD report issued 2021, lost CTG traces, cardiology medical devices not being retained/quarantined/inspected in a timely fashion leading to relevant data being overwritten or devices destroyed – informal letter sent 2026).
The Trust must ensure a culture that promotes a forensic inquiring mind, supported by robust systems to promptly identify and retain evidence, especially as a number of the medical devices used across the Trust are not networked or cloud based, meaning data can be lost when the device is switched off or memory is overwritten when the device is next used.
” Source location Jennifer Susan BIRCH · 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 download accurate clinical data from medical devices promptly
Wider context from the report “1. (NUH) Failure to ensure an “inquiring mind” in satisfying the duty of candour
The Trust can only seek to learn lessons from events if it has, at every level, an inquiring mind that seeks to capture all relevant evidence at the earliest opportunity following clinical events.
My investigation, and that of the PSII, was hampered by the failure of staff to complete a Datix report on the day of the event. This led to a failure to quarantine the medical equipment used in theatre (which was suspected of potential malfunction), a failure to download all accurate clinical data from the machines , and a failure to retain the second, retrospectively completed, anaesthetic chart.
This is not an isolated incident, nor one that is unique to this Department. This is a Trust wide issue. Coronial investigations over recent years have been hampered in establishing the truth because of a failure by the Trust to retain relevant material post clinical events (placentas disposed of following neonatal harm – PFD report issued 2021, lost CTG traces, cardiology medical devices not being retained/quarantined/inspected in a timely fashion leading to relevant data being overwritten or devices destroyed – informal letter sent 2026).
The Trust must ensure a culture that promotes a forensic inquiring mind, supported by robust systems to promptly identify and retain evidence, especially as a number of the medical devices used across the Trust are not networked or cloud based, meaning data can be lost when the device is switched off or memory is overwritten when the device is next used .
” Source location Jennifer Susan BIRCH · 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 retain relevant clinical material after clinical events
Wider context from the report “1. (NUH) Failure to ensure an “inquiring mind” in satisfying the duty of candour
The Trust can only seek to learn lessons from events if it has, at every level, an inquiring mind that seeks to capture all relevant evidence at the earliest opportunity following clinical events.
My investigation, and that of the PSII, was hampered by the failure of staff to complete a Datix report on the day of the event. This led to a failure to quarantine the medical equipment used in theatre (which was suspected of potential malfunction), a failure to download all accurate clinical data from the machines, and a failure to retain the second, retrospectively completed, anaesthetic chart .
This is not an isolated incident, nor one that is unique to this Department. This is a Trust wide issue. Coronial investigations over recent years have been hampered in establishing the truth because of a failure by the Trust to retain relevant material post clinical events (placentas disposed of following neonatal harm – PFD report issued 2021, lost CTG traces , cardiology medical devices not being retained /quarantined/inspected in a timely fashion leading to relevant data being overwritten or devices destroyed – informal letter sent 2026).
The Trust must ensure a culture that promotes a forensic inquiring mind, supported by robust systems to promptly identify and retain evidence, especially as a number of the medical devices used across the Trust are not networked or cloud based, meaning data can be lost when the device is switched off or memory is overwritten when the device is next used.
” Source location Jennifer Susan BIRCH · 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 Strengthen incident-reporting, device-quarantine and evidence-retention policies through governance ratification and publication.
Verbatim wording from the response “i. Strengthening Policy Framework:” Source location Response from NUH
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop, approve and disseminate SOPs specifying device security, data preservation, storage, testing and manufacturer engagement after device safety events.
Verbatim wording from the response “ii. Introduction of new Standard Operating Procedures (SOPs)” Source location Response from NUH
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and distribute clinical-area visual aids prompting immediate evidence-preservation actions and sources of support.
Verbatim wording from the response “iii. Visual Prompts and Frontline Support” Source location Response from NUH
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deliver Trust-wide multiprofessional training on prompt reporting, candour, device quarantine, data preservation and related safety processes.
Verbatim wording from the response “iv. Training and Workforce Development” Source location Response from NUH
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review opportunities to reduce reliance on non-networked devices and improve immediate access to device information.
Verbatim wording from the response “Planned Improvements and Assurance” Source location Response from NUH
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit evidence-retention practices one year after policy launch.
Verbatim wording from the response “Planned Improvements and Assurance” Source location Response from NUH
Open published response
11 Dec 2025 Mrs Ashana Charles · Prevention of Future Deaths report South London
View report summary
Concerns raised 1
Failure to retain infusion equipment and supplies for forensic investigation View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mrs Ashana Charles · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Ashana Charles died suddenly in hospital on 20 November 2018 after an unexpected cardiac arrest during intravenous feeding. The inquest concluded that cellulose fibres from inadvertently contaminated intravenous infusions caused acute obstruction of small pulmonary arteries, and that the death would have been prevented by using a 1.2-micron filter, which was not standard practice at the time. Concerns included the failure to retain infusion equipment for forensic investigation, inconsistent guidance and practice on filters, and uncertainty about the adequacy of batch-based visual checks of parenteral nutrition products.
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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 retain infusion equipment and supplies for forensic investigation
Wider context from the report “1. That no source of contamination could be identified due to the infusion set, filter, feeding bag and lines not being retained for forensic investigation . The pathologist Professor ████████ gave an opinion that deaths that might be associated with IV feeding were probably underreported due to inadequate investigation.
2. ████████, expert pharmacist and pharmaceutical regulator drew attention to
a) The inconsistency at the time between US and European and UK guidance about use of filters in parenteral feeding (PN).
b) Reference to filters for Omega Special by the drug manufacturer at the time indicating an appropriate filter “if one was used”, but not its need or desirability or context of use, and the value of manufacturers and health providers integrating their approach to risk management.
c) The use of the 1.2 micron filter at the time was not standard practice, perhaps because of cost or operational reasons as the filter often led to blockages and delays in IV feeding. Now both that BNPG guidance and B Braun recommend the use of 1.2 micron filters on Omega Special label, but that does not give assurance that all PN and filter manufacturers issue the same guidance nor that their products are operationally consistent with guidance.
d) Lewisham & Greenwich NHS Trust have begun to re-evaluate the use of 1.2 micron filters in PN feeding but the matter had not yet gone to its governance department but should do so next year. There was a need for those responsible for decision implementation in hospitals nationally to cross work with manufacturers and specialist bodies.
e) Uncertainty whether the reported visual checks of PN products by batch rather than individually provided adequate safety assurance.
” Source location Mrs Ashana Charles · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to immediately store or freeze stomach contents for triggering-allergen analysis View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Benedict BLYTHE · 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
Benedict died at Peterborough City Hospital on 1 December 2021, aged 5, from fatal anaphylaxis following accidental exposure to cow’s milk protein. The report identifies concerns about the retention and testing of samples, including blood and stomach contents, and the police seizure and retention of relevant evidence such as vomitus during investigations of unexplained deaths.
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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 immediately store or freeze stomach contents for triggering-allergen analysis
Wider context from the report “1) In relation to Pathology
That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis:
a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens
b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen
c. blood samples if taken at hospital should not be destroyed but retained for testing
d. that an early blood sample is taken after death and stored for later analysis
e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity
f. tissue samples are taken and retained.
g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation.
2.) The police investigation:
In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner.
” Source location Benedict BLYTHE · 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 Publish autopsy guidelines for suspected acute anaphylaxis, including blood and stomach-content sampling guidance.
Verbatim wording from the response “The Kennedy Protocol has not been formally updated since 2016; it is not known when or if the protocol is to be revised. Since then Autopsy guidelines have been published on sudden unexpected death in infancy and childhood in 2023 under the remit of the Death Investigation Committee at the Royal College of Pathologists and these have superseded the 2016 publication. Neither the 2016 or 2023 guidelines included samples in cases of suspected anaphylaxis. However, the RCPath published autopsy guidelines on autopsies for suspected acute anaphylaxis (includes anaphylactic shock and anaphylactic asthma) in 2018. This document does include very specific guidance of sampling blood and stomach contents in such cases together with caveats for interpreting mast cell tryptase levels.” Source location Response from Royal College of Pathologists
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 Published anaphylaxis autopsy guidance and expected use of relevant guidance are considered sufficient despite paediatric guidelines lacking specific anaphylaxis details.
Verbatim wording from the response “The Kennedy Protocol has not been formally updated since 2016; it is not known when or if the protocol is to be revised. Since then Autopsy guidelines have been published on sudden unexpected death in infancy and childhood in 2023 under the remit of the Death Investigation Committee at the Royal College of Pathologists and these have superseded the 2016 publication. Neither the 2016 or 2023 guidelines included samples in cases of suspected anaphylaxis. However, the RCPath published autopsy guidelines on autopsies for suspected acute anaphylaxis (includes anaphylactic shock and anaphylactic asthma) in 2018. This document does include very specific guidance of sampling blood and stomach contents in such cases together with caveats for interpreting mast cell tryptase levels.” Source location Response from Royal College of Pathologists
Open published response
Concerns raised 1
Failure to retain emergency department monitor data for retrospective analysis View source
This report raised 21 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christian James Gabriel Hobbs · 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
Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.
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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 retain emergency department monitor data for retrospective analysis
Wider context from the report “POINT N - DATA FROM EMERGENCY DEPARTMENT ALARMS
The monitor evidence was not available for analysis of heart rhythms etc because there was no retention of the data at the time . This hampered consideration of data in the death that required detailed review and this is a concern.
” Source location Christian James Gabriel Hobbs · 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 Install a central Emergency Department monitoring area with printers to retain and print alarm data.
Verbatim wording from the response “N. Data from Emergency Department Alarms
The parameters at which alarms are sounded can be adjusted by staff on a temporary basis. Notwithstanding this, the monitors are still visible to staff in the Resuscitation area. As was explained at the inquest, the Emergency Department has subsequently installed a central monitoring area with printers. There is therefore no problem in retaining or printing off data if this is required. Unfortunately, in Christian’s case, the Trust was not informed of any concerns in this respect until some considerable time after Christian’s death. The monitors that we had at that time would need to have been interrogated prior to being used on the next patient. This is no longer an issue with the new equipment that we have but once again data will only be stored for a limited period of time.” Source location Response from North West Anglia NHS Foundation Trust
Open published response
30 Aug 2024 Terence Harry Clark · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to secure and document clinical apparatus relevant to investigations View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Terence Harry Clark · 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
Terence Harry Clark, who had an impaired swallow and aspiration pneumonia, was admitted to hospital on 26 October 2023 and died there on 1 November 2023 after sustaining a cardiac arrest while waiting unescorted in an X-ray waiting area. Concerns included the discovery of liquid food in his airway, the unexplained removal and loss of his naso-gastric tube, and the failure to identify the tube’s removal as a significant factor during the patient safety investigation, which impeded investigation of the death.
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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 secure and document clinical apparatus relevant to investigations
Wider context from the report “A. Despite Mr Clark having been subject to a nil-by-mouth order for 24 hrs prior to collapse, cream-coloured liquid food was found in Mr Clark’s airway at autopsy. The NG tube, inserted on the day of death had been removed and misplaced prior to autopsy. No evidence exists to indicate, when the apparatus was removed, by whom, on whose instruction or why. The removal and loss of this apparatus impeded the proper investigation of this death.
” Source location Terence Harry Clark · 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 and update the Bereavement policy to clarify when tubes, lines and devices remain in situ after sudden or unexpected death, including medical examiner involvement.
Verbatim wording from the response “Following this case, we are reviewing the Bereavement policy to clarify the guidance around removal of tubes, lines and devices. Where a sudden or unexpected death has occurred, the policy will mandate that tubes, lines and devices are left in situ until after:” Source location Response from Barts Health
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 the removal guidance at safety huddles with senior nursing and site teams to reinforce a lower threshold for coroners’ office discussion.
Verbatim wording from the response “This case has already been discussed at our safety huddles, with the senior nursing and site teams to underline the above and ensure a lower threshold for discussion with the coroners office should there be any doubt about removal of lines etc. Any conversation will be documented in the patient record.
We will be cascading the learning from this incident and embedding this within training across the Trust.” Source location Response from Barts Health
Open published response
28 Mar 2024 Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1
Failure to retain recordings of calls for serious patient incident investigations View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ellen Ocean WOOLNOUGH · 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
Ellen Ocean WOOLNOUGH was found suspended by a ligature at her home on 20 July 2022 after concerns had arisen about her physical and mental health. Resuscitation restored circulation, but she suffered an irreversible hypoxic brain injury and died in hospital on 28 July 2022. The principal concerns relate to mental health service discharge decisions after failed engagement, the response to urgent referrals including risk assessment and safety planning, the implementation of the Patient Safety Incident Response Framework, and the preservation of call recordings and other evidence.
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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 retain recordings of calls for serious patient incident investigations
Wider context from the report “iv. Changes to the way the Trust investigates incidents such as Ellie’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust.
” Source location Ellen Ocean WOOLNOUGH · 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 Revise the patient-safety screening form to prompt retrieval and preservation of available patient-call recordings for investigations and inquests.
Verbatim wording from the response “4. Changes to the way the Trust investigates incidents such as Ellen’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust, and” Source location Response from Norfolk and Suffolk NHS Foundation Trust
Open published response
17 Jan 2023 Teegan Marie Barnard · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Failure to download and interrogate anaesthetic machine data after a suspected equipment-related event View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Teegan Marie Barnard · 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
Teegan Marie Barnard suffered a prolonged PEA cardiac arrest during emergence from general anaesthesia after an emergency caesarean section, following significant postpartum haemorrhage and bilateral tension pneumothoraces. She sustained a non-survivable hypoxic brain injury and died at home six weeks later. Concerns included failure to consider and promptly recognise tension pneumothoraces during resuscitation, and inadequate investigation, clinical governance and learning after her death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to download and interrogate anaesthetic machine data after a suspected equipment-related event
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated , which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” Source location Teegan Marie Barnard · 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 Amend guidance to require a standardised investigation process automatically triggered immediately after a catastrophic event.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
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 Promote the amended catastrophic-event investigation process to the anaesthesia specialty.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
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 Embed the amended catastrophic-event investigation process through the Royal College of Anaesthetists’ Anaesthesia Clinical Services Accreditation scheme.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review guidance to identify the need for a standardised investigation process automatically triggered after catastrophic events.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend guidance to specify a standardised investigation process automatically triggered immediately after catastrophic events.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote the amended catastrophic-event investigation process to the anaesthesia specialty.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the amended catastrophic-event investigation process through the Royal College of Anaesthetists’ Anaesthesia Clinical Services Accreditation scheme.
Verbatim wording from the response “We have reviewed our guidance in light of your report and we have recognised that we should be more explicit about the need for a standardised process of investigation which is automatically triggered immediately after a catastrophic event. This should ensure that responsibility for steps such as downloading information from the anaesthetic machine or the temporary removal of equipment from service for checking, is removed from those directly involved. We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA’s Anaesthesia Clinical Services Accreditation scheme. We also note that the implementation of our recommendation that all departments should have an appropriate electronic anaesthetic record system, linked to the wider electronic patient record, would aid the investigation of incidents.” Source location Response from Royal College of Anaesthetists
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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 RCoA is responsible for clarifying anaesthetic-machine arrangements in its guidance, while CQC will respond to the report and recommendations.
Verbatim wording from the response “Regarding your concerns around there being no temporary removal of the anaesthetic machine used in this case, or the downloading of information from the machine, we welcome RCoA’s commitment to update its guidance accordingly, to ensure responsibilities around this are made more explicit. We are also aware that the Care Quality Commission (CQC) will be issuing a response to your Report and will review their response and any recommendations made in due course.” 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 identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
Verbatim wording from the response “I write in response to your report of 17 January 2023, made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I have been asked to respond on behalf of Health Education England. Please may I start by offering my sincere condolences to the family of Teegan Marie Bernard, following her tragic death. However, having carefully considered the report, together with the facts of the case, we believe that whilst there are valuable lessons to be learned; Unfortunately, these do not come within the scope of HEE’s current role and statutory responsibilities.” Source location Response from Health Education England
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21 Nov 2022 Celia Lindsey MARSH · Prevention of Future Deaths report Avon
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Concerns raised 2
Failure to obtain and preserve stomach contents and tissue samples at post-mortem examination View source Failure to retain hospital blood samples in suspected anaphylaxis cases View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Celia Lindsey MARSH · 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
Celia Lindsey Marsh died on 27 December 2017 after suffering fatal anaphylaxis caused by milk protein in a wrap she believed was safe to eat. The principal concerns included the investigation and retention of evidence in suspected anaphylaxis deaths, education for doctors and patients, systems for reporting anaphylaxis, and potentially misleading “dairy-free” and other allergen-labelling claims.
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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 and preserve stomach contents and tissue samples at post-mortem examination
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Source location Celia Lindsey MARSH · 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 retain hospital blood samples in suspected anaphylaxis cases
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Source location Celia Lindsey MARSH · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establishing the systems identified by the Coroner falls outside UKHSA’s remit.
Verbatim wording from the response “Whilst we understand the seriousness of the failings leading to the death of Celia Marsh responsibility for establishing systems such as those referred to by the Coroner sit outside of the remit of UKHSA.” Source location Response UK Health Security Agency
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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 Pathology policy responsibility lies with DHSC and the Royal College of Pathologists, rather than the respondent.
Verbatim wording from the response “Your concerns regarding pathology have been noted, however this is not an area where the FSA has policy responsibility. I can see that your report has been directed to the Department for Health and Social Care (DHSC) and the Royal College of Pathologists who may be able to offer a response to these concerns. We are however, open to assisting other government departments where we can.” Source location Response from Food Standards Agency
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15 May 2022 Connor Samuel Timothy Wellsted · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure to retain medical records after sudden unexpected deaths View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Connor Samuel Timothy Wellsted · 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
Connor Samuel Timothy Wellsted, a five-year-old boy with significant neuro-disabilities, was found deceased in his cot on 17 May 2017 during a residential neuro-rehabilitation stay. The investigation determined that he died following entrapment by a loose cot bumper causing airway obstruction. Concerns included inadequate cot maintenance and securing, lack of regular direct visual night-time supervision, and failures to preserve the scene, inform relevant bodies, and investigate the circumstances openly and transparently.
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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 retain medical records after sudden unexpected deaths
Wider context from the report “3. Probity and Investigation by the Children’s Trust, Tadworth
The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.
Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns . Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death.
Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death.
The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant.
” Source location Connor Samuel Timothy Wellsted · 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 Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.
Verbatim wording from the response “I note that you also sent your Report to the Chief Executive and Medical Director of the Children’s Trust, Tadworth, and I have had sight of their response as referred to above. On 15 July 2022, representatives from the South East Region attended upon the Trust and carried out a comprehensive review of all of the points that you made in your Report. They concluded that there were no current quality concerns, however there was room for improvement. The outstanding actions for improvement will continue to be monitored by NHS England South East. I am assured that the Children’s Trust, Tadworth, have addressed all of the concerns raised in your Report.” Source location Response from NHS England
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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 clear protocols and training for unexpected child deaths using relevant national and local guidance.
Verbatim wording from the response “In addition to this, we have reviewed The Royal College of Pathologists guidelines on ‘Sudden unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation’, 2016, and guidance produced by the Surrey Child Death Review Partnership. We are further developing a clear protocol and training for our nursing and medical staff in the event of an unexpected child death. We accept that our training has historically focussed on basic life support and actively assessing and supporting children who we do not anticipate will die unexpectedly. Whilst our staff will continue to receive their basic life support training, we will have clear guidelines on processes and actions to be taken in the event of a sudden unexpected death. We are also planning to expand our existing simulation training beyond medical emergencies and basic life support, to cover unexpected deaths.” Source location Response from The Children's Trust
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21 Oct 2021 Quinn Lias Parker · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Failure to retain the placenta for full paediatric post mortem examination before coronial reporting View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Quinn Lias Parker · 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
Quinn Lias Parker was born in very poor condition and died two days later, after remaining extremely unwell from shortly after birth. The placenta was cut into or dissected after his death without discussion with the Coroner, limiting the paediatric post-mortem examination and the investigation into the circumstances and likely cause of death. The report also identifies repeated cases in which placental examination was compromised following early neonatal deaths in Nottingham.
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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 retain the placenta for full paediatric post mortem examination before coronial reporting
Wider context from the report “1. The placenta, a key organ required for a full paediatric post mortem in an early neonatal death, has been interfered with such that the Paediatric Pathologist, is limited in his conclusion as to the likely cause of death.
In some ways the placenta is akin to an organ for the purposes of a paediatric post mortem- Loss of an organ at any post mortem examination, may well undermine the ability of the pathologist to carry out a full and proper examination. Decisions surrounding interference with, or disposal of, the placenta should be made in a careful and considered manner, with thought given to an early discussion with the coroner as would happen if organ donation is being considered. This did not happen in this case.
2. Unfortunately, there have been a number of cases in Nottingham where the death of a baby shortly after the birth was anticipated, but the placenta was disposed of and/or interfered with prior to the death being reported to the coroner . This undermines the coronial investigation resulting in limited findings and therefore limited conclusions at inquest. This will likely lead to a lack of learning from such deaths, and therefore a risk that similar deaths will occur in the future. It may also deprive the parents of significant information when considering whether future pregnancies may be at greater risk with the consequent need for appropriate management and planning.
3. The Nottinghamshire Coronial service has to date worked collaboratively with all local Trusts, but particularly with NUH NHS Trust, to ensure key staff understand the importance of retaining the placenta in an early neonatal death. This has not led to the actions necessary to achieve a full and proper examination of the placenta in repeated paediatric post mortems in this jurisdiction.
” Source location Quinn Lias Parker · 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 a 96-hour stop on dissecting placentas sent to Pathology, allowing fixation during the period without dissection.
Verbatim wording from the response “Last year, in the light of your PFD report, an immediate 48 hour stop was put on the dissection of all placentas. However we have since reviewed the proposed processes and the length of that stop has been extended and is now set at 96 hours (ie 4 days) for all placentas that are sent to Pathology. A placenta may be fixed during that period, to prevent its deterioration, but it will not be dissected.” Source location Response from NUH (3)
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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 whether placental examination processes need adaptation after receiving further information about the examination.
Verbatim wording from the response “In response to this Report the Trust will develop a standard procedure such that in the case of any neonatal death within 48 hours of birth the medical examiner team will inform the pathology laboratory of this at the very earliest opportunity. Once further information is gained in relation to the placental examination the Pathology Department will review whether there needs to be any adaptation to current examination processes.” Source location Response from NUH
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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 Trust considers a process to identify very unwell neonates for pre-death Coroner discussions impractical and unreliable because deaths are not predictable.
Verbatim wording from the response “After consultation with Obstetricians, Neonatologists, Pathologists and Digital Lead, it is the view of the Trust that it is not proportionate nor practically achievable to devise a process that would reliably allow for this given that all of the 975 admissions to NICU each year are, by the very nature of NICU, neonates who are very unwell and may go on to die. The death of a neonate on NICU is not predictable in a way that could reliably allow us to identify the 25 or so neonates who do actually die each year. This is why we have determined that extending the Pathology stop period across the board for all placentas, and having discussions with your office where a death occurs within 96 hours, is a preferable and more realistically achievable approach.” Source location Response from NUH (3)
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Includes failures of controls specifically dedicated to identifying, securing, retaining, downloading, quarantining or preserving clinical evidence and data after serious clinical events, including medical-device data, monitoring records, clinical apparatus and other material physical or documentary evidence.
