6 Dec 2018 Simon Healey · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Failure of escalation arrangements to provide emergency assessment by critical care-competent staff 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
Independent Healthcare Providers Network
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
Independent Healthcare Providers Network
Continue a CQC learning programme to understand outstanding safety practice and support its adoption across independent healthcare providers.
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Independent Healthcare Providers Network
Discuss escalation policies in independent acute hospitals with the CQC.
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Independent Healthcare Providers Network
Conduct a scoping exercise on providers’ assurance of staff awareness of NEWS and sepsis training.
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Independent Healthcare Providers Network
Encourage providers to establish formal service-level agreements with neighbouring providers for higher-acuity care transfers.
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Simon Healey · 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
Simon Healey underwent right hemi-colectomy on 1 August 2017 and died on 10 August 2017 after an anastomotic leak led to faecal peritonitis, E. coli septicaemia and organ failure. The principal concerns were missed opportunities to detect the leak and sepsis earlier, inadequate escalation of care under NEWS protocols, the suitability of private hospitals’ staffing and facilities for such procedures, and an inadequate hospital investigation.
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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 escalation arrangements to provide emergency assessment by critical care-competent staff
Wider context from the report “(1) I believe that the NEWS policies in place at private hospitals should be reviewed. This relates not only to awareness of the policy and sepsis training generally, but also consideration of the arrangements for escalating care where a patient becomes critically unwell. Most private hospitals do not have a full critical care capacity (in terms of facilities and staff) and rely instead on a consultant’s availability to attend and review the position. The Royal College of Physicians NEWS trigger thresholds have been adopted almost verbatim by this hospital, save for the category relating to the sickest patients. Whilst the trigger thresholds in the RCP documents do need to be tailored to the organisation in question, it would appear, based on the information I have been provided with, that something well below an “emergency response” can be provided in this hospital, and perhaps also the wider private sector. RCP guidelines clearly require “emergency assessment by a team with critical care competencies”. The escalation policy at Ramsay Healthcare hospitals currently (for a patient scoring 7 or above) is for the registered nurse “to immediately inform the RMO and named consultant. The named consultant to attend urgently and review the patient and agree action to be taken. Consider transfer of care to a level 2 or 3 clinical care facility i.e. HDU or ICU” . This policy clearly anticipates initial review by a consultant, outside the hospital, who may well not be available to attend on an emergency basis.
” Source location Simon Healey · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue a CQC learning programme to understand outstanding safety practice and support its adoption across independent healthcare providers.
Verbatim wording from the response “The CQC’s State of care in independent acute hospitals published in April 2018 did cite examples of inconsistent monitoring of risks and examples where effective escalation did not occur within providers. In order to address this and other quality related findings, IHPN began a learning programme with the CQC to ensure that their view of what makes for outstanding care in the Safe domain is fully understood throughout the sector so that best practice can be adopted across the board.” Source location 2018-0378-Response-by-IHPN
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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 Discuss escalation policies in independent acute hospitals with the CQC.
Verbatim wording from the response “IHPN’s formal engagement with the CQC includes frequent catch-up meetings to discuss quality themes across the sector. It also comprises joint CQC-IHPN seminars where providers share best practice and learn from each other. Previous seminars have focused on safety and well-led. We will be discussing escalation policies in independent acute hospitals with the CQC in February.” Source location 2018-0378-Response-by-IHPN
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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 a scoping exercise on providers’ assurance of staff awareness of NEWS and sepsis training.
Verbatim wording from the response “In order to support this agenda item, IHPN will undertake a scoping exercise on how providers assure themselves of levels of staff awareness of NEWS and on sepsis training. This will assist us to identify if these two elements of this unfortunate case are indeed reflected across the wider sector.” Source location 2018-0378-Response-by-IHPN
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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 Encourage providers to establish formal service-level agreements with neighbouring providers for higher-acuity care transfers.
Verbatim wording from the response “It is clear from the CQC’s end of programme report that more work needs to be done to formalise the arrangements some independent providers have in place to deal with deteriorating patients and we have strongly encouraged all providers to have formal Service Level Agreements in place with neighbouring healthcare providers able to provide higher acuity care in the event of a patient’s health deteriorating unexpectedly. However, we are confident that the overall picture for the sector is good. IHPN members already have clear processes in place to manage deterioration and, where necessary, to arrange the transfer of patients to higher acuity settings.” Source location 2018-0378-Response-by-IHPN
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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 Patient transfer does not indicate inappropriate originating care or admission, and independent hospitals can safely manage unanticipated deterioration through planned transfer arrangements.
Verbatim wording from the response “Inter-hospital transfers are a well embedded mechanism to ensure that patients are treated in the most appropriate place should unanticipated complications arise. These transfers take place between providers of all types – from NHS providers to other NHS providers, from independent providers to independent providers, and from independent providers to NHS providers and vice versa.” Source location 2018-0378-Response-by-IHPN
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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 There is no evidence that patient transfers are particularly associated with hospitals lacking intensive-care facilities, and national guidance does not require on-site intensive care.
Verbatim wording from the response “We are not aware of any evidence to suggest that transfers of patients are particularly associated with providers who do not have intensive care facilities, such as NHS community and district general hospitals, mental health inpatient units and some independent sector hospitals. The NICE guidelines on patient transfers do not suggest that patients should only be treated where there are” Source location 2018-0378-Response-by-IHPN
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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 Independent hospitals already have clear processes to manage deterioration and arrange transfers to higher-acuity settings when necessary.
Verbatim wording from the response “It is clear from the CQC’s end of programme report that more work needs to be done to formalise the arrangements some independent providers have in place to deal with deteriorating patients and we have strongly encouraged all providers to have formal Service Level Agreements in place with neighbouring healthcare providers able to provide higher acuity care in the event of a patient’s health deteriorating unexpectedly. However, we are confident that the overall picture for the sector is good. IHPN members already have clear processes in place to manage deterioration and, where necessary, to arrange the transfer of patients to higher acuity settings.” Source location 2018-0378-Response-by-IHPN
Open published response
9 Oct 2018 Tom Cribley · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 2
Failure to escalate monitoring and management after grossly abnormal blood results View source Delays in escalating NEWS to medical staff View source
This report raised 10 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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Tom Cribley · 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
Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.
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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 escalate monitoring and management after grossly abnormal blood results
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results , the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Source location Tom Cribley · 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 Delays in escalating NEWS to medical staff
Wider context from the report “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017.
Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness.
The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions.
Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area.
” Source location Tom Cribley · Prevention of Future Deaths report
Open source report
4 Jul 2018 Kathleen Margaret Allen · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to apply a consistent MEWS escalation pathway in the Emergency Department View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Kathleen Margaret Allen · 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
Kathleen Margaret Allen died at Birmingham Heartlands Hospital on 20 March 2018 from the effects of aspiration pneumonia caused by small bowel obstruction, after she was initially diagnosed with gastroenteritis. The report states that delayed investigation, insufficient monitoring and lack of senior medical review meant the severity of her condition was not identified promptly, and that her death was preventable. A principal concern was the inconsistent application of MEWS escalation procedures in the Emergency Department, with staff receiving different instructions and a risk to patient safety.
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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 apply a consistent MEWS escalation pathway in the Emergency Department
Wider context from the report “3. Evidence was provided from an ED Senior Sister that there is a Trust Standard Operating Procedure (SOP) for MEWS Triggers in the Emergency Department which is different to the Trust wide SOP . The rationale behind having a different Procedure in ED was said to be because Doctors are more widely available in ED than on the wards. Within this SOP a MEWS of between 1 and 3 is not escalated to the Nurse in Charge . It was accepted by the witness that the rationale for a different procedure based on Doctor availability does not explain why the Nurse in Charge is not informed for a patient with a MEWS of 1 to 3. It was suggested that the explanation for this may in fact be because so many ED patients have a MEWS of between 1 and 3 the Trust wide MEWS SOP would be unworkable. A copy of this Procedure was not put before the inquest but was said to still be in operation at Birmingham Heartlands Hospital.
4. It therefore appears that there is not a consistent approach to MEWS SOP in Birmingham Heartlands ED : members of staff are being told different things and there appears to be a different procedure in operation to that set out in documents within patient records . There is a risk that staff within ED will not be taking a consistent, evidence based approach to MEWS and also that non ED based clinicians, reviewing patients in ED will not be aware of the difference in MEWS procedure operating in ED and therefore will expect a different escalation pathway. This could put lives at risk.
” Source location Kathleen Margaret Allen · 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 Deploy an ED-specific MEWS Observation Chart across BHH and Good Hope Emergency Departments and Solihull Minor Injuries Unit.
Verbatim wording from the response “Notwithstanding the induction process, the Trust accepts that the use of the ward MEWS Observation Chart in ED can lead to confusion. Consequently, an ED-specific MEWS Observation Chart has now been deployed for use in the BHH and, Good Hope EDs, and the Solihull Minor Injuries Unit. Further, the ED MEWS SOP is available for all directorate teams to access on the Trust intranet. The ED directorate have circulated an email to the Divisional Directors across HGS sites asking them to disseminate the ED MEWS SOP and remind their speciality clinical teams that a separate escalation pathway for MEWS in ED is in use.” Source location 2018-0213-Response-by-University-Hospitals-Birmingham-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make the ED MEWS Standard Operating Procedure available to directorate teams on the Trust intranet.
Verbatim wording from the response “Notwithstanding the induction process, the Trust accepts that the use of the ward MEWS Observation Chart in ED can lead to confusion. Consequently, an ED-specific MEWS Observation Chart has now been deployed for use in the BHH and, Good Hope EDs, and the Solihull Minor Injuries Unit. Further, the ED MEWS SOP is available for all directorate teams to access on the Trust intranet. The ED directorate have circulated an email to the Divisional Directors across HGS sites asking them to disseminate the ED MEWS SOP and remind their speciality clinical teams that a separate escalation pathway for MEWS in ED is in use.” Source location 2018-0213-Response-by-University-Hospitals-Birmingham-NHS-Trust
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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 Disseminate the ED MEWS Standard Operating Procedure and remind speciality clinical teams that a separate ED escalation pathway is in use.
Verbatim wording from the response “Notwithstanding the induction process, the Trust accepts that the use of the ward MEWS Observation Chart in ED can lead to confusion. Consequently, an ED-specific MEWS Observation Chart has now been deployed for use in the BHH and, Good Hope EDs, and the Solihull Minor Injuries Unit. Further, the ED MEWS SOP is available for all directorate teams to access on the Trust intranet. The ED directorate have circulated an email to the Divisional Directors across HGS sites asking them to disseminate the ED MEWS SOP and remind their speciality clinical teams that a separate escalation pathway for MEWS in ED is in use.” Source location 2018-0213-Response-by-University-Hospitals-Birmingham-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 In emergency departments, MEWS scores of 1–3 do not routinely require Nurse in Charge escalation without overriding clinical concern or deterioration.
Verbatim wording from the response “The MEWS escalation pathway in ED does differ from that which applies to the wards. As the Area Coroner identified, the escalation pathway documented on the back of Mrs Allen’s MEWS Observation Chart required, for a MEWS score of between 1 and 3, consideration of increasing the frequency of observations and escalation to the Nurse in Charge. In ED, however, for a MEWS score between 1 and 3, there is an expectation that patient’s observations are completed hourly, but escalation to the Nurse in Charge is not routinely required unless there is an overriding clinical concern or deterioration in the patient’s condition (that is to say, the MEWS is a safeguard, but clinical staff should not allow it to override their clinical judgement).” Source location 2018-0213-Response-by-University-Hospitals-Birmingham-NHS-Trust
Open published response
8 Feb 2018 Howard Winter · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure to escalate neck or back pain findings to a doctor for reassessment, investigation and diagnosis View source
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AI-generated summary
Howard Winter · 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
Howard Winter, a resident of Daffodils CH with vascular dementia and frequent falls, fell on 23 August 2017, sustained a serious head injury, was diagnosed with a spinal fracture on 11 September, developed pneumonia and died in hospital on 16 September 2017. The principal concern was that recorded neck and back pain following his initial attendances was not escalated to a doctor for reassessment, investigation and diagnosis, potentially contributing to an adverse outcome if repeated.
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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 escalate neck or back pain findings to a doctor for reassessment, investigation and diagnosis
Wider context from the report “████████ gave evidence at the Inquest that on the 26.8.17 an auxiliary nurse had recorded in the nursing notes – “pain in neck/back – unable to score”. There was no evidence – written or otherwise, to demonstrate an escalation of this finding to a doctor for re-assessment, investigation & diagnosis.
████████ evidence to the Inquest was that this ought to have occurred .
Whilst this apparent absence of escalation may not necessarily have affected the outcome for Mr Winter, were it to be repeated now, or in the future, the outcome for the patient involved could be potentially causative of/contribute towards death/adverse outcome .
” Source location Howard Winter · 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 Conduct two Health Board-wide audits of NEWS score completion and escalation.
Verbatim wording from the response “1. Two audits have been undertaken across the Health Board to measure how the NEWS scores are completed and escalated.” Source location 2018-0040-Response-by-University-Health-Board
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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 Progress improvement work in priority clinical areas identified through the NEWS audit.
Verbatim wording from the response “The audit has identified the need for further education and training as well as raising awareness amongst nursing and medical staff in relation to accurate documentation and escalation. The audit has also identified priority clinical areas for improvement work which will be progressed.” Source location 2018-0040-Response-by-University-Health-Board
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16 Oct 2017 Jeremy Michael Holt · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 2
Failure to empower nursing staff to refer critically ill patients to the Critical Care Outreach Team View source Lack of an available and understood fallback escalation pathway when Critical Care Outreach cannot assess a patient 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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Jeremy Michael Holt · 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
Jeremy Michael Holt Marshall developed a small bowel obstruction and other complications after elective surgery for colonic adenocarcinoma, deteriorated in hospital, and died on 17 November 2016 after life support was withdrawn. Concerns included delays in escalating his deteriorating condition, insufficiently specified review and fallback arrangements, and inadequate recording of observations for a critically ill patient with a high NEWS score.
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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 empower nursing staff to refer critically ill patients to the Critical Care Outreach Team
Wider context from the report “2. Review Point and fall back position when no further action is forthcoming – ████████ and also ████████ care plan at midnight provided for action to be undertaken but neither care plan provided for a specific timescale for any further review in respect of a patient who was quite clearly critically ill. Both ████████ indicated that with the benefit of hindsight that such a timescale would have been desirable. I am concerned that if there is not a review or further action undertaken and noted within a period of time which at the end of the day has to be reasonable but given the critical nature of patient scoring 7 and above should be relatively short, that if nothing happens that the nursing staff are empowered to refer the matter now to the Critical Care Outreach Team. My concern goes further than that. If hypothetically the Critical Care Outreach Team at a time of significant demand were unable to assess a patient then there needs to be built into that system a fallback position similar to the same fallback position that is available to the doctors ie that the nursing team can contact ITU or even as a last resort on the call Consultant. I am satisfied and I have no doubt in my similar situation that ████████ would have no hesitation in making such a call but I am concerned as to whether or not other members of the nursing team would be aware of those options and that is of concern to me as well as the reinforcement of a review point for a critically ill patient to be actually recorded in the care plan.
” Source location Jeremy Michael Holt · 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 an available and understood fallback escalation pathway when Critical Care Outreach cannot assess a patient
Wider context from the report “2. Review Point and fall back position when no further action is forthcoming – ████████ and also ████████ care plan at midnight provided for action to be undertaken but neither care plan provided for a specific timescale for any further review in respect of a patient who was quite clearly critically ill. Both ████████ indicated that with the benefit of hindsight that such a timescale would have been desirable. I am concerned that if there is not a review or further action undertaken and noted within a period of time which at the end of the day has to be reasonable but given the critical nature of patient scoring 7 and above should be relatively short, that if nothing happens that the nursing staff are empowered to refer the matter now to the Critical Care Outreach Team. My concern goes further than that. If hypothetically the Critical Care Outreach Team at a time of significant demand were unable to assess a patient then there needs to be built into that system a fallback position similar to the same fallback position that is available to the doctors ie that the nursing team can contact ITU or even as a last resort on the call Consultant. I am satisfied and I have no doubt in my similar situation that ████████ would have no hesitation in making such a call but I am concerned as to whether or not other members of the nursing team would be aware of those options and that is of concern to me as well as the reinforcement of a review point for a critically ill patient to be actually recorded in the care plan.
” Source location Jeremy Michael Holt · 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 Operate a 24-hour continuity plan that routes critical-care support to ITU nursing or ICU medical staff when outreach is unavailable.
Verbatim wording from the response “The Trust has a continuity plan in place so that if the critical care outreach team are not available the bleep is passed to the nurse in charge of ITU or the ICU doctor. This ensures that there is always staff available to provide support when required. The system has been operational 24 hours a day since January 2017 and therefore has been in place during period of winter pressure and has proved to be an effective and beneficial resource in improving patient safety. This is demonstrated by review of ITU admissions and the latest report shows that for the unplanned admissions there is an improving trend in the medical plans being documented and appropriate escalation being undertaken. In addition the number of medical emergency team calls has reduced.” Source location 2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing continuity and escalation arrangements ensure staff are always available to support escalation when critical care outreach is unavailable.
Verbatim wording from the response “The Trust has a continuity plan in place so that if the critical care outreach team are not available the bleep is passed to the nurse in charge of ITU or the ICU doctor. This ensures that there is always staff available to provide support when required. The system has been operational 24 hours a day since January 2017 and therefore has been in place during period of winter pressure and has proved to be an effective and beneficial resource in improving patient safety. This is demonstrated by review of ITU admissions and the latest report shows that for the unplanned admissions there is an improving trend in the medical plans being documented and appropriate escalation being undertaken. In addition the number of medical emergency team calls has reduced.” Source location 2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
Open published response
28 Jul 2017 Pamela Keech · Prevention of Future Deaths report Northamptonshire
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Concerns raised 1
Failure to escalate fistula/graft-site bleeds for renal or surgical review 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
Pamela Keech · 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
Pamela Keech, who had end-stage renal failure and received haemodialysis through a leg graft, experienced repeated bleeds from the graft site before being found unconscious with substantial blood loss on 7 July 2015. She died from a catastrophic haemorrhage from the graft site. Concerns included the lack of national guidance and training on predicting and managing fatal graft or fistula haemorrhage, and whether patients with such bleeds are escalated for renal or surgical review.
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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 escalate fistula/graft-site bleeds for renal or surgical review
Wider context from the report “(3) I am concerned that other patients presenting with bleeds from fistula/graft sites might not be escalated for renal/surgical review before a fatal bleed presents .
” Source location Pamela Keech · 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 Request an expert review of UK ambulance clinical practice guidelines for renal patients, specifically covering fistula bleeds.
Verbatim wording from the response “The action that we will be taking is to request that JRCALC, acting as our expert clinical advisors, review the UK ambulance service clinical practice guidelines for the management of renal patients and specifically in relation to fistula bleeds. We will ensure that any recommendations for new or updated guidance is written, published and issued to our ambulance clinicians as part of our ongoing clinical practice guideline development plan.” Source location 2017-0327-Response-by-Association-of-Ambulance
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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 Write, publish and issue any resulting new or updated fistula-bleed guidance to ambulance clinicians through the clinical practice guideline development plan.
Verbatim wording from the response “The action that we will be taking is to request that JRCALC, acting as our expert clinical advisors, review the UK ambulance service clinical practice guidelines for the management of renal patients and specifically in relation to fistula bleeds. We will ensure that any recommendations for new or updated guidance is written, published and issued to our ambulance clinicians as part of our ongoing clinical practice guideline development plan.” Source location 2017-0327-Response-by-Association-of-Ambulance
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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 specialist advice from the Vascular Access Society of Britain & Ireland on fistula bleeds and hospital conveyance when bleeding has stopped.
Verbatim wording from the response “In addition, have written to the Vascular Access Society of Britain & Ireland to seek specialist advice in relation to fistula bleeds and whether patients should always be conveyed to hospital, particularly when bleeding has stopped. There may be opportunities to develop pathways for our clinicians to have direct clinical discussions with a vascular specialist regarding the most appropriate pre-hospital management of a patient and to agree whether conveying the patient to hospital is required.” Source location 2017-0327-Response-by-Association-of-Ambulance
Open published response
16 Jun 2017 Mrs Macrae · Prevention of Future Deaths report Northamptonshire
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Concerns raised 1
Failure to seek attendance by the attending spinal surgeon for postoperative instability View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mrs Macrae · 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 Macrae was admitted for elective lumbar spinal surgery and experienced intermittent drops in blood pressure during recovery. The report raises concern that internal haemorrhage was not considered as a possible cause of her instability and that this rare but recognised complication should be understood after similar surgery.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to seek attendance by the attending spinal surgeon for postoperative instability
Wider context from the report “1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend . Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability.
2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery.
” Source location Mrs Macrae · 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 Require both the Consultant Surgeon and Consultant Anaesthetist to attend when either is recalled or a deteriorating patient requires escalation.
Verbatim wording from the response “• As standard practice now since this tragic outcome, if an anaesthetist or surgeon is re-called to the hospital, both Consultant Surgeon and Consultant Anaesthetist are asked to attend. The Senior Management Team (SMT) who provide on call support 24/7 are all very clear on this and ensure this happens as part of the escalation process for any deteriorating patient, or when a Consultant is asked to return to the hospital.” Source location 2017-0193-Response-by-Woodlands-Hospital
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 and finalise education standards incorporating standards on patient assessment, management of deterioration, and surgery-related complications.
Verbatim wording from the response “We are currently undertaking a wholesale review of our education standards, including the pre-registration standards of proficiency that nurses must meet before being registered with us. We intend that these new standards of proficiency for registered nurses will include specific standards relating to patient assessment and the management of patient deterioration. We are undertaking a full public consultation on the draft standards, which is due to conclude on 12 September 2017, following which we will carefully review the feedback we receive from our stakeholders before finalising the standards. We will also take into account the concerns you have raised in your report about complications of surgery.” Source location 2017-0193-Response-by-NMC
Open published response
Concerns raised 1
Failure to seek medical direction on future management after a peri-arrest View source
This report raised 13 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
Michael John NEWELL · 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
Michael John Newell died following an admission involving haemorrhage, decompensated liver failure and associated coagulopathy. Concerns included a lack of awareness among emergency and surgical staff of the significance of his liver failure, inadequate recognition and treatment of hypovolaemia, lack of consultant ENT input, weaknesses in the mortality review process, and nursing documentation and management issues.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to seek medical direction on future management after a peri-arrest
Wider context from the report “(5) the conduct of the Nurse in charge of the ward of making no notes after her presence at a peri-arrest, neither seeking or obtaining any direction from the medical team as to future management , not directing any further resuscitation in accordance with documented medical plans in the notes and lack of completion of the fluid balance chart would suggest that the Trust's procedures for determining which nurse clinicians may lead a nursing shift should be reviewed.
” Source location Michael John NEWELL · Prevention of Future Deaths report
Open source report
16 Mar 2017 James Charles MALLETT · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Delays and failures in escalating serious patient deterioration to senior medical staff View source
This report raised 10 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
James Charles MALLETT · 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
James Charles Mallett, aged 93, was admitted to hospital after a fall at home and later sustained a fatal head injury in a further inpatient fall. Concerns included delayed medical attendance, unclear and untimely neurological observations, inadequate contemporaneous records, insufficient falls prevention, and nursing staff training and experience that were considered inadequate.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays and failures in escalating serious patient deterioration to senior medical staff
Wider context from the report “(2) There was no apparent urgency to secure the prompt attendance of a doctor to assess the patient . The nursing staff, who were described by Sr Snowden as a "junior workforce" did not seem to understand the seriousness of the injury and did not seek senior help from the night team . The nursing staff did not carry out regular and/or timely neurological observations.
” Source location James Charles MALLETT · Prevention of Future Deaths report
Open source report
11 Oct 2016 Barry THOMPSON · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 1
Failure to act on elevated National Early Warning Scores View source
This report raised 9 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
Barry THOMPSON · 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
Barry Thompson, an insulin-dependent diabetic, died on 27 February 2016 while a patient on the Acute Medical Unit, after being admitted with sepsis from diabetic foot ulcers and hyperglycaemia. The report identified concerns about failure to provide insulin, fluids, adequate monitoring, antibiotics and medical review, as well as inaccurate and incomplete records and ineffective information sharing during transfer between departments.
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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 act on elevated National Early Warning Scores
Wider context from the report “(1) Non-compliance with National and Local protocols:
Mr Thompson was triaged as a high priority on admission to the Emergency department at 12.37 am on 26th February 2016. It is recorded that he not had his morning insulin. He was not seen by a doctor nor given antibiotics within an hour according to the National Standard and the (Hospital’s) Sepsis Pathway. He was seen by a doctor at 16.52 (although his case was drawn to the attention of a doctor earlier by a nurse and instructions given for care). Further a NEWS score of 7 (National Early Warning Score) was not actioned according to policy which would have resulted in Mr Thompson being reviewed by at least middle grade doctor immediately .
” Source location Barry THOMPSON · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.