6 Aug 2022 Ernest Bacon · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to escalate non-compliance with the sepsis policy View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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Ernest Bacon · 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
Ernest Thomas Bacon suffered an accidental fall at home, sustained a fractured neck of femur, and was admitted to Tameside General Hospital, where he subsequently had an ischaemic stroke. After triggering for sepsis on 16 January 2022, he was not reviewed face to face, the sepsis pathway was not followed, intravenous antibiotics were delayed, and the failure to escalate was not recognised. He died from sepsis at the hospital on 17 January 2022.
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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 non-compliance with the sepsis policy
Wider context from the report “4. The nursing team recognised that he was triggering for Sepsis but the notes were not flagged and the failure to follow the Sepsis policy was not escalated in accordance with Trust Policy . The reason for non-escalation was unclear.
” Source location Ernest Bacon · Prevention of Future Deaths 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 Conduct monthly internal spot-check audits of sepsis pathway compliance and report non-compliance through incident forms.
Verbatim wording from the response “To provide internal assurance spot check audits have been implemented to specifically look at compliance with the sepsis pathway. The audits have commenced and include a review of 10 patients each month. Where compliance with the pathway has not been present, an incident form will be completed contemporaneously.” Source location Response from Tameside and Glossop Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run a Trust-wide incident-reporting programme addressing incident and near-miss identification, reporting, learning and action.
Verbatim wording from the response “In addition to this, there has been a Trust wide focus on incident reporting throughout the month of September 2022. This work has been underway across the organisation and is being led by the Assistant Director of Integrated Governance throughout, culminating in the Trust’s Patient Safety Conference on October 6th 2022. This programme of events and activities seeks to engage staff at all levels and focusses on identification of incidents or near misses, incident reporting, acting on and learning from incidents.” Source location Response from Tameside and Glossop Integrated Care
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Concerns raised 1
Inadequate escalation procedures for care 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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Joan RICHARDSON · 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
Joan RICHARDSON, a frail 98-year-old woman living in supported accommodation, became increasingly unwell at home and was admitted to hospital on 4 May 2020. She had pneumonia, a fractured neck of femur and grade 4 sacral pressure wounds, and died in hospital on 18 May 2020. Concerns included failures to escalate her deterioration and pain, incomplete care planning and risk assessments, inadequate pressure-area care and documentation, and inadequate staff training and escalation procedures.
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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 Inadequate escalation procedures for care staff
Wider context from the report “(brief summary of matters of concern)
Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;-
1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc.
2. When Joan complained of pain -the matter was not escalated as it should have been.
3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital.
4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment.
5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly.
6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required.
” Source location Joan RICHARDSON · Prevention of Future Deaths report
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16 Sep 2021 Mrs Tripta Bhanote · Prevention of Future Deaths report Black Country
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Concerns raised 1
Lack of clarity among care staff about escalation requirements for acutely unwell patients or residents View source
This report raised 2 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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Mrs Tripta Bhanote · 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 Tripta Bhanote, who was 86 and living in a residential care home, was found on the floor on several occasions in May 2020 and her condition then declined rapidly before she died. Concerns included unclear procedures for escalating acute illness to emergency services, uncertainty about referral to the enhanced care and quality team, and poor procedures for identifying residents’ DNAR status.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clarity among care staff about escalation requirements for acutely unwell patients or residents
Wider context from the report “1. Evidence emerged during the inquest that there was a lack of clarity and understanding by care staff in the requirements for escalation to emergency services when a patient/resident becomes acutely unwell .
” Source location Mrs Tripta Bhanote · Prevention of Future Deaths report
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26 Apr 2021 Alan Massam · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of a defined escalation process for refusal of medication and fluids View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Alan Massam · 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
Alan Massam, a resident with dementia, had repeated falls after moving to a dementia residential home and was twice admitted to hospital. After a traumatic brain bleed and rib fractures were identified, he deteriorated and died in hospital on 24 October 2019. Concerns included inadequate information-sharing between agencies, discharge without effective communication or confirmation that the care home could meet his needs, and the absence of a clear escalation process when he refused medication and fluids.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a defined escalation process for refusal of medication and fluids
Wider context from the report “3. The staff at the home were aware of the prescribing of medication including antibiotics. However when he refused them and fluids there was no defined escalation process which would ensure that the risk this presented was recognised and acted on .
” Source location Alan Massam · 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 Undertake an unannounced targeted inspection of Lisburne Court covering the concerns raised in the prevention of future death report.
Verbatim wording from the response “Upon receipt of the concerns raised within the Regulation 28 report issued to CQC by the Coroner on 26 April 2021 a decision was made to undertake an unannounced targeted inspection of Lisburne Court. The findings of this inspection will be shared with the Coroner. This will be completed to ensure that the circumstances of Mr Massam’s death do not reflect any ongoing risk to people currently living at the home.” Source location 2021-0120-Response-from-CQC-Redacted
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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 arrangements requiring contact with the GP provide the escalation route when care-home patients refuse medication or fluids.
Verbatim wording from the response “Future actions will include the implementation of Trusted Assessment training for all staff.
Point 3 – escalation process in care homes for patients refusing medication.
In any situation where a patient is not accepting prescribed medication and is declining fluid intake then contact should be made to the patient’s GP so that a decision can be” Source location 2021-0120-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted
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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 When patients refuse prescribed medication or fluids, their GP should decide the appropriate next steps.
Verbatim wording from the response “I understand that the Greater Manchester Health and Social Care Partnership recommends that where a patient is not accepting prescribed medication or fluids, then contact should be made to the patient’s GP so that a decision can be made in relation to next steps.” Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted
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Concerns raised 1
Lack of clear direction in the post-falls process on when to call 999/111 for possible or suspected head injury View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Hampshire County Council
Review and update the falls protocol in line with current NICE guidance, directing staff to contact 999 or 111.
View source
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Arthur Edward 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
Arthur Edward JOHNSON died on 20 April 2020 after an unwitnessed fall at a residential home caused a head injury and intracerebral haemorrhage; a spontaneous intracranial haemorrhage also contributed to the death. Concerns were raised that the residential home’s post-falls process did not clearly distinguish between possible and suspected head injury or specify when 999/111 should be called, and about staff training to recognise intracranial injury.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear direction in the post-falls process on when to call 999/111 for possible or suspected head injury
Wider context from the report “Oakridge House Residential Home is staffed by non-medically trained personnel.
The “Post-Falls” process/policy direct that 999/111 should be called when a head injury is suspected.
The evidence at inquest indicated that where a head injury was considered a possibility 999/111 was not called.
My concern is that the present process does not give adequate direction, provide sufficient clarity nor distinguish between “possible” and “suspected” head injury. It is not clear when 999/111 should be called.
Further, I have concerns in relation to the training provided to assist Residential Home staff in the recognition of intracranial injury.
” Source location Arthur Edward JOHNSON · Prevention of Future Deaths 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 falls protocol in line with current NICE guidance, directing staff to contact 999 or 111.
Verbatim wording from the response “I understand that when you requested the documentation for Mr Johnson’s inquest, you received only part of the current “falls protocol”. As a result of your recommendations the entire protocol has been reviewed and updated in line with current NICE guidance. This clearly directs staff to contact 999 or 111. The revised protocol is attached and I trust addresses the concern relating to the clarity of practice guidance.” Source location 2021-0003-Response-from-Hampshire-County-Council-Redacted
Open published response
Concerns raised 1
Absence of a policy or procedure for escalating concerns about patient condition and delayed admission 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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Samantha Brousas · 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
Samantha Brousas became critically ill with suspected sepsis and was taken to hospital, where she was diagnosed with septic shock secondary to pneumonia and died from a naturally occurring infection. The report identified concerns about the absence of a pre-alert to the emergency department, the inability of paramedics to administer intravenous antibiotics, and the lack of a clear process for escalating concerns about delayed admission.
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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 Absence of a policy or procedure for escalating concerns about patient condition and delayed admission
Wider context from the report “(3) During the course of the inquest I heard evidence that both paramedics attending the deceased had significant concerns about both the patient’s condition and the delay in admission into the ED. Despite these concerns, neither paramedic escalated these concerns either through Ambulance Control or through hospital escalation channels (which were known to Ambulance Control). My concern is that there was an absence of a policy or procedure whereby staff could escalate such concerns thereby missing an opportunity to highlight individual cases requiring immediate escalation in the absence of any clear management plan for the patient’s admission .
” Source location Samantha Brousas · Prevention of Future Deaths 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 Design an agreed escalation process for crews when emergency department staff do not act on their clinical concerns.
Verbatim wording from the response “Patients in the Emergency Department or held in the back of the Emergency Ambulance on the forecourt are recognised in the 2016 Welsh Health Circular as the responsibility of the Health Board. As such, at all times, Trust crews should be able to escalate any clinical concerns directly to the Emergency Department via the ambulance triage nurse, nurse in charge or other senior clinician and reasonably expect action to be taken. Given the findings of the inquest, the Trust are actively designing an agreed escalation process that crews can use on the occasions that their concerns are not felt to be acted upon by staff in the Emergency Department.” Source location 2019-0443-Response-from-the-Welsh-Ambulance-Services
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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 Health Boards are responsible for patients in Emergency Departments or ambulances held on hospital forecourts, including addressing escalated clinical concerns.
Verbatim wording from the response “Patients in the Emergency Department or held in the back of the Emergency Ambulance on the forecourt are recognised in the 2016 Welsh Health Circular as the responsibility of the Health Board. As such, at all times, Trust crews should be able to escalate any clinical concerns directly to the Emergency Department via the ambulance triage nurse, nurse in charge or other senior clinician and reasonably expect action to be taken. Given the findings of the inquest, the Trust are actively designing an agreed escalation process that crews can use on the occasions that their concerns are not felt to be acted upon by staff in the Emergency Department.” Source location 2019-0443-Response-from-the-Welsh-Ambulance-Services
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27 Nov 2019 Andrew Richard Hogg · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of an escalation pathway following sequential falls View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Borough Care Ltd
Arrange a GP or CPN review for any resident experiencing more than two falls within two weeks.
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Andrew Richard Hogg · 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
Andrew Richard Hogg, who had Parkinson’s disease and possible dementia, died on 6 May 2019 after a fall at Meadway Court Care Home caused a head injury and subdural haematoma. The principal concerns were the absence of adequate falls assessment, escalation, investigation and proactive measures to reduce the risk after his repeated falls.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of an escalation pathway following sequential falls
Wider context from the report “I heard evidence of the sequence of falls which I have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019. There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk.
In evidence I heard from ████████ who was the manager of the home (although I accept he was only recently in post). ████████ having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:-
1. Not all the relevant paperwork was completed following the falls
2. There could have been engagement with other services such as the local falls clinic
3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder”
4. Relevant information should have been updated onto the patient’s electronic record.
While I welcome his insightful comments I remain concerned that
1. There was no adequate falls assessment policy
2. There was no obvious escalation pathway following the sequential falls Andrew had
3. There was no internal investigation into any of the falls which occurred
4. There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct care supervision.
It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing.
While it cannot be said that had such steps been taken Andrew would not have fallen when he did, I do think that the risk of that happening would have been substantially reduced.
” Source location Andrew Richard Hogg · Prevention of Future Deaths 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 Arrange a GP or CPN review for any resident experiencing more than two falls within two weeks.
Verbatim wording from the response “However, to tighten up our process all home managers will be reviewing falls on our PCS (Person Centered Software) system on a weekly basis to ensure that falls are monitored more frequently. Managers will print the falls log for the week and add notes as to what actions have been taken. These notes will also be added to the support plans of those residents involved. Collectively as a group of managers we have also agreed that any resident who has more than two falls within a two week period we will arrange a review with their GP or CPN.” Source location 2019-0400-Response-from-Borough-Care-Ltd-Redacted
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4 Oct 2019 Pamela Evans · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1
Mismatch between critical care outreach call guidance and nurses’ understanding of the call threshold View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
The Trust
Deliver direct NEWS2 training to nursing staff, including escalation based on clinical judgement as well as numerical scoring.
View source
The Trust
Provide tools and mechanisms for identifying deteriorating patients and clarify escalation routes using clinical experience alongside numerical scoring.
View source
The Trust
Use trust-wide clinical updates, shared-learning sessions and safety bulletins to reinforce deterioration recognition and escalation.
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Pamela Evans · 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 Evans, aged 87, fell and hit her head at Bedford Hospital after becoming dizzy while walking to the toilet, and died on 4 November 2018 from a large right-sided acute on chronic subdural haematoma. Concerns included inconsistent understanding among nurses about when to call the critical care outreach team, limited action that team could initially take, errors in recording her NEWS, and failures to identify these issues through the Trust’s serious incident 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 Mismatch between critical care outreach call guidance and nurses’ understanding of the call threshold
Wider context from the report “(i) A mismatch between:
(a) on the one hand, the expressed intention of senior nursing staff as to when nurses should call the critical care outreach team if the relevant medical team is unable to attend, namely that nurses should call when they have concerns about a patient, irrespective of the patient’s NEWS score
and
(b) on the other hand, the understanding of at least some nurses that they cannot or will not call the outreach team, despite having concerns, unless the NEWS score exceeds a specific number (5 or above, according to the cardiac nurse practitioner who cared for the deceased; 7 or above, according to a doctor setting out her experience of some nurses’ practice).
” Source location Pamela Evans · Prevention of Future Deaths 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 Deliver direct NEWS2 training to nursing staff, including escalation based on clinical judgement as well as numerical scoring.
Verbatim wording from the response “The Trust takes patient safety seriously and is compliant with our duties to implement national patient safety initiatives. NEWS2 was launched in September 2018 and the trust had to report compliance by April 2019 and undertook:” Source location 2019-0333-Response-by-Bedford-Hospital-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide tools and mechanisms for identifying deteriorating patients and clarify escalation routes using clinical experience alongside numerical scoring.
Verbatim wording from the response “Absence of evidence that staff know the routes of escalation for deteriorating patients
I apologise if at the time of the inquest Trust representatives were not able to provide you with assurance on staff knowledge regarding the routes for escalation for deteriorating patients. The trust has undertaken substantial work over the past two years on identifying and escalating deteriorating patients. Part of which has been to:” Source location 2019-0333-Response-by-Bedford-Hospital-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use trust-wide clinical updates, shared-learning sessions and safety bulletins to reinforce deterioration recognition and escalation.
Verbatim wording from the response “Absence of evidence that staff know the routes of escalation for deteriorating patients
I apologise if at the time of the inquest Trust representatives were not able to provide you with assurance on staff knowledge regarding the routes for escalation for deteriorating patients. The trust has undertaken substantial work over the past two years on identifying and escalating deteriorating patients. Part of which has been to:” Source location 2019-0333-Response-by-Bedford-Hospital-NHS-Trust
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17 May 2019 Jenson James Francis · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure to use the escalation policy View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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Jenson James Francis · 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
Jenson James Francis was delivered by caesarean section and developed chorioamnionitis and funisitis in the context of maternal sepsis. The report records cardio-pulmonary failure following a failure to deliver him in good time and states that he was exposed to the effects of developing maternal sepsis. Principal concerns included poor CTG interpretation and training, unclear clinical leadership and communication, inadequate records, insufficient staffing and escalation, and wider systemic shortcomings in the maternity unit.
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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 use the escalation policy
Wider context from the report “(5) There were insufficient staffing levels, and very high acuity, despite which there was no consultant attendance and the escalation policy was not used . There was evidence that there was no clear line of responsibility for identifying this and ameliorating it.
” Source location Jenson James Francis · 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 Deliver mandatory training on communication, record keeping, documentation and escalation, with compliance monitoring.
Verbatim wording from the response “There is an Organisational Development Action Plan to focus on many areas of the multiprofessional teams in maternity services. Within the plan there is support for multidisciplinary team working and clinical leadership. Included in the plan are two study days in July and October 2019 supported by the Royal College of Midwives to improve clinical leadership and team working within the department. The mandatory professional training days include sessions on communication, record keeping and documentation and escalation. This plan focuses on individual team members as well as groups. PROMPT is now fully implemented into the Health Board with all staff booked for training before the end of March 2020. Training compliance is monitored through the HB Maternity Improvement Board.” Source location 2019-0158-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 Implement an escalation policy, incident-reporting process and senior-midwife out-of-hours escalation rota.
Verbatim wording from the response “There is a new escalation policy and staff are incident reporting times of high acuity this is being monitored via datix reporting. There is a senior midwife on call rota to support staff with any concerns in clinical practice out of hours and for concerns about escalation.” Source location 2019-0158-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 Implement the Birthrate Plus labour-ward acuity system and support staff to use it for timely escalation.
Verbatim wording from the response “Birthrate plus acuity system for labour ward has been implemented into the unit and staff are currently being supported to use this to support timely escalation.” Source location 2019-0158-Response-by-University-Health-Board
Open published response
25 Feb 2019 John William Pearce · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Lack of clear escalation instructions for worsening open wounds 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
Central and North West London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Central and North West London NHS Foundation Trust
Apply the Lower Limb and Leg Ulcer Management Policy to standardize wound management and escalation across the Trust.
View source
Central and North West London NHS Foundation Trust
Reinforce the wound policy, escalation responsibilities, emergency-services role, qualified-nurse attendance, reassessment, and risk-factor management with the involved team.
View source
Central and North West London NHS Foundation Trust
Hold a follow-up meeting to assess embedded learning and systematic identification of deteriorating patients at handovers.
View source
Central and North West London NHS Foundation Trust
Oversee reassessment of wound-care competence for all relevant staff.
View source
Central and North West London NHS Foundation Trust
Cascade a Trust-wide clinical message reminding community nursing teams about wound policy, consent, capacity, and escalation requirements.
View source
Central and North West London NHS Foundation Trust
Share case learning through the clinical-message process, a learning event, and the Pressure Ulcer Board.
View source
Central and North West London NHS Foundation Trust
Retrain team members to use the NEWS2 tool for identifying deterioration and seeking emergency help.
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John William Pearce · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John William Pearce was a frail 90-year-old man who developed a worsening left knee wound after an injury in April 2018 and died in hospital on 21 September 2018. The report identified concerns about delayed hospital referral, insufficient district nursing attendances, reliance on his reluctance to attend hospital, and inadequate systems for recognising and sharing information about worsening wounds.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear escalation instructions for worsening open wounds
Wider context from the report “I am concerned that:
(a) There was no clear instruction, protocol or system which assists nursing staff in dealing with elderly patients who suffer from open wounds which worsen over time, as to when the emergency services should be contacted . It is clear that the staff were following a Tissue Viability Nurse care plan, but no-one appeared to recognise the severity of the injury and the fact that tendons and bone were exposed ;
(b) There were insufficient attendances on Mr Pearce by the District Nurse Team when it appeared to be decided that he would be visited at more frequent intervals;
(c) Too much emphasis was placed on Mr Pearce’s own view that he did not like hospitals and did not want to go there, even though he was noted to be an individual who had difficulty expressing himself;
(d) There was no clear evidence that photographs taken of the wound were shared with other agencies or the deceased’s GP, such that another view could be taken of those wounds so as to consider whether the emergency services should become involved as a matter of urgency.
” Source location John William Pearce · 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 Apply the Lower Limb and Leg Ulcer Management Policy to standardize wound management and escalation across the Trust.
Verbatim wording from the response “CNWL has a Lower Limb and Leg Ulcer Management Policy which was published in October 2018 and gives detailed instructions on the management of lower limb wounds, including traumatic non healing wounds as seen in this case. The purpose of the policy is to standardise lower limb and leg ulcer management strategies across the Trust in accordance with NICE (2016), Best Practice Statement (2016) and RCN (2006) guidance.” Source location 2019-0068-Response-by-CNWL-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 Reinforce the wound policy, escalation responsibilities, emergency-services role, qualified-nurse attendance, reassessment, and risk-factor management with the involved team.
Verbatim wording from the response “It is completely unacceptable that this policy was not consistently adhered to by the staff involved in Mr Pearce’s care. In response to this, the Divisional Director of Nursing and the Inner London Lead Nurse met with the team involved in this gentleman’s care on 19 March 2019 to discuss the findings of the PFD, reiterate the policy and assess any further support required in ensuring the above policy is followed in the future.” Source location 2019-0068-Response-by-CNWL-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 Hold a follow-up meeting to assess embedded learning and systematic identification of deteriorating patients at handovers.
Verbatim wording from the response “A further follow up meeting is planned with the team on 3 May 2019 to assess how the team have embedded learning from this incident to date including their local processes for ensuring that at handovers, deteriorating patients are identified in a systematic manner.” Source location 2019-0068-Response-by-CNWL-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 Oversee reassessment of wound-care competence for all relevant staff.
Verbatim wording from the response “All of our district nurses complete annual refresher training on wound care management. There is a competency framework in place for health care assistants and district nurse team leaders are responsible for ensuring that their staff are competent. In light of these findings, the Lead Nurse will oversee a programme for reassessment of competence and this will be completed for all staff by 1 June 2019.” Source location 2019-0068-Response-by-CNWL-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 Cascade a Trust-wide clinical message reminding community nursing teams about wound policy, consent, capacity, and escalation requirements.
Verbatim wording from the response “In addition, a Trust-wide clinical message will be cascaded out to all community nursing teams reminding them of the policy requirements, consent and capacity and escalation processes.” Source location 2019-0068-Response-by-CNWL-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 Share case learning through the clinical-message process, a learning event, and the Pressure Ulcer Board.
Verbatim wording from the response “As identified above, the learning from this case will be shared across the Trust as part of our “clinical message of the week” process during the next month. The case will also be shared at a planned learning event with staff, GP and colleagues from Whittington Health on 9 May 2019.” Source location 2019-0068-Response-by-CNWL-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 Retrain team members to use the NEWS2 tool for identifying deterioration and seeking emergency help.
Verbatim wording from the response “CNWL has a deteriorating patient policy which identifies actions staff need to take to identify when patients clinical condition changes. The policy requires that staff in adult services use the National Early Warning Score (NEWS2) tool which directs staff to seek emergency help. CNWL will re-train members of the team in the use of this tool by the end of May 2019.” Source location 2019-0068-Response-by-CNWL-NHS-Trust
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.