Concerns raised 3
Tele-tracking system failing to support clear transport communication View source Lack of clear porter responsibilities when nursing staff are unavailable View source Failure to provide clear allocation and communication of transport assessment responsibilities View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Shrewsbury and Telford Hospital NHS Trust
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
the Shrewsbury and Telford Hospital NHS Trust
Put in place a radiology patient-transport Standard Operating Procedure incorporating the new transfer process.
View source
the Shrewsbury and Telford Hospital NHS Trust
Include transport roles and responsibilities in the wider Hospital Transfer Policy through the Trust ratification process.
View source
the Shrewsbury and Telford Hospital NHS Trust
Recommunicate the requirement that nursing staff assist Porters with patient transfers through a Trust safety alert, meetings, and written instructions to Porters.
View source
the Shrewsbury and Telford Hospital NHS Trust
Implement a radiology transfer form requiring registered-nurse assessment, documentation, and sign-off before transfer and on return.
View source
the Shrewsbury and Telford Hospital NHS Trust
Review the transfer form with key staff to ensure dynamic risk assessment and clear nursing documentation before patient transfer.
View source See 2 more actions
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AI-generated summary
William Arthur John SIMONS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Arthur John SIMONS died following two falls while receiving treatment at Royal Shrewsbury Hospital, with the second fall identified as more significant and preventable. Concerns included confusion and communication failures in the Tele-tracking transport system, unclear responsibilities when nursing staff were unavailable to assist a patient, and inadequate awareness of the patient's falls risk.
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 Tele-tracking system failing to support clear transport communication
Wider context from the report “(1) The Tele-tracking system
a) It was not clear what the purpose was of a doctor expressing a preferred option of transport (i.e. by trolley/bed) if that doctor did not have sufficient information to make it.
b) Whilst it became clear that that option was subject to review by the nursing staff on the ward it was not clear why a doctor would not either liaise with the nursing staff or expressly make it clear that the nursing staff should make that assessment and inform the porters accordingly.
c) The system on the day led to confusion and a breakdown in communication with the patient being taken instead by wheelchair with his zimmer frame.
(2) Assistance.
It was established that assisting a patient to move meant by a member of the nursing staff and not a porter. It should be clear what a porter is to do if no nursing staff is available.
(3) Risk awareness.
The porter did not know the patient’s level of risk of falls.
” Source location William Arthur John SIMONS · 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 Lack of clear porter responsibilities when nursing staff are unavailable
Wider context from the report “(1) The Tele-tracking system
a) It was not clear what the purpose was of a doctor expressing a preferred option of transport (i.e. by trolley/bed) if that doctor did not have sufficient information to make it.
b) Whilst it became clear that that option was subject to review by the nursing staff on the ward it was not clear why a doctor would not either liaise with the nursing staff or expressly make it clear that the nursing staff should make that assessment and inform the porters accordingly.
c) The system on the day led to confusion and a breakdown in communication with the patient being taken instead by wheelchair with his zimmer frame.
(2) Assistance.
It was established that assisting a patient to move meant by a member of the nursing staff and not a porter. It should be clear what a porter is to do if no nursing staff is available.
(3) Risk awareness.
The porter did not know the patient’s level of risk of falls.
” Source location William Arthur John SIMONS · 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 provide clear allocation and communication of transport assessment responsibilities
Wider context from the report “(1) The Tele-tracking system
a) It was not clear what the purpose was of a doctor expressing a preferred option of transport (i.e. by trolley/bed) if that doctor did not have sufficient information to make it.
b) Whilst it became clear that that option was subject to review by the nursing staff on the ward it was not clear why a doctor would not either liaise with the nursing staff or expressly make it clear that the nursing staff should make that assessment and inform the porters accordingly .
c) The system on the day led to confusion and a breakdown in communication with the patient being taken instead by wheelchair with his zimmer frame.
(2) Assistance.
It was established that assisting a patient to move meant by a member of the nursing staff and not a porter. It should be clear what a porter is to do if no nursing staff is available.
(3) Risk awareness.
The porter did not know the patient’s level of risk of falls.
” Source location William Arthur John SIMONS · 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 Put in place a radiology patient-transport Standard Operating Procedure incorporating the new transfer process.
Verbatim wording from the response “• A Standard Operating Procedure (SOP) for Transporting Patients to and from Radiology has been put in place and this new process has been included in that (enclosed).” Source location 2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
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 Include transport roles and responsibilities in the wider Hospital Transfer Policy through the Trust ratification process.
Verbatim wording from the response “• The process, including roles and responsibilities, will be included in a new wider Hospital Transfer Policy. This has been drafted and is currently going through the Trust’s ratification process.” Source location 2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
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 Recommunicate the requirement that nursing staff assist Porters with patient transfers through a Trust safety alert, meetings, and written instructions to Porters.
Verbatim wording from the response “This was communicated as part of the SI and Porters DO NOT transfer patients from chair to wheelchair or bed without the assistance of a nurse when being transferred off or onto the ward.” Source location 2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
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 Implement a radiology transfer form requiring registered-nurse assessment, documentation, and sign-off before transfer and on return.
Verbatim wording from the response “The mode of transport to the department for the investigation for an inpatient is specified on the form by the doctor making the request. This should be done in discussion with the nursing staff. However, the patient’s condition may change from the time of the request to the investigation being undertaken and so a further assessment should be made by the registered nurse (RN) caring for the patient at the time of transfer of the patient.” Source location 2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
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 the transfer form with key staff to ensure dynamic risk assessment and clear nursing documentation before patient transfer.
Verbatim wording from the response “• A review of the form has taken place with all key staff, to ensure this is a dynamic risk assessment, and there is clear documentation for the RN caring for the patient prior to the patient being transferred to and from an investigation/procedure.” Source location 2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
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 Wheelchair transport was appropriate because the patient mobilised with assistance and was comfortable sitting, although the assessment process was undocumented.
Verbatim wording from the response “The mode of transport to the department for the investigation for an inpatient is specified on the form by the doctor making the request. This should be done in discussion with the nursing staff. However, the patient’s condition may change from the time of the request to the investigation being undertaken and so a further assessment should be made by the registered nurse (RN) caring for the patient at the time of transfer of the patient.” Source location 2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
Open published response
1 Feb 2019 Mary Bertha Johnson · Prevention of Future Deaths report Herefordshire
View report summary
Concerns raised 1
Insufficient porter availability limiting theatre operations View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mary Bertha 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
Mary Bertha Johnson died at County Hospital, Hereford, on 25 July 2018 after falling on 20 July 2018 and sustaining a periprosthetic fracture of the femur. Concerns included poor communication about feeding and medication before surgery, and the suggestion that porter availability affected the hospital theatres’ ability to carry out operations.
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 Insufficient porter availability limiting theatre operations
Wider context from the report “(2) It was suggested that the availability of porters determined the ability of the hospital theatres to carry out operations
” Source location Mary Bertha Johnson · 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 Porter availability had no material effect on the patient's outcome.
Verbatim wording from the response “The investigation has established that the availability of porters had no material effect on this patient’s outcome.” Source location 2019-0458-Response-by-Wye-Valley-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.