Recurring concern

Unreliable post-operative monitoring and clinical review

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First reported 27 Jan 2015•Latest report 13 Dec 2024

Definition

What this concern includes

Includes failures in dedicated post-operative monitoring and clinical review, including required observations and early-warning checks, suitable monitoring environments, additional monitoring for relevant vulnerabilities, and adequate medical oversight of post-operative reviews.

Not included

Excludes failures in the operation itself or pre-operative assessment.
Excludes general post-operative treatment, wound care, discharge, rehabilitation or long-term follow-up where monitoring or clinical review is not the deficient control.
Excludes generic staffing, communication, documentation or care-planning deficiencies unless they directly impair post-operative monitoring or clinical review.
Excludes failures after adequate monitoring and review have identified deterioration where the remaining issue is treatment or escalation.

Reports: 13
Individual concerns: 17
Date range: 2015–2024
Stated actions: 32

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Barking, Havering and Redbridge University Hospitals NHS Trust1

British Society Of Gastroenterology1

Cornwall Partnership NHS Foundation Trust1

Department of Health and Social Care1

East Surrey Hospital1

Homerton Healthcare NHS Foundation Trust1

Independent Healthcare Providers Network1

Manchester University NHS Foundation Trust1

Medway NHS Foundation Trust1

Moorfields Eye Hospital NHS Foundation Trust1

Portsmouth Hospitals University NHS Trust1

Ramsay Health Care UK1

Recipient name withheld1

Royal College of Pathologists1

Royal College of Radiologists1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

23 Mar2016
Mid Kent and Medway
Concerns raised1
1. Failure to inspect the surgical wound
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Incorporate infection-status and wound-care documentation into the new nursing assessment and care-planning document.
  Stated by The TrustStated planned
2. Action
  Update tissue-viability policy and procedures with NICE guidance and post-operative surgical-wound management standards.
  Stated by The TrustStated in progress
3. Action
  Review wound-care documentation, care plans and wound-assessment standards.
  Stated by The TrustStated completed
1. Action
  Present wound-care documentation and standards to safety and nursing quality forums and cascade them through directorates.
  Stated by The TrustStated planned
2. Action
  Monitor compliance with wound-care policies and procedures through established assurance audits and governance forums.
  Stated by The TrustStated completed
AI-generated summary

Alwyn Ann Head · 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

Alwyn Ann Head was admitted to hospital after falls caused a fractured femur at the site of a prosthesis. She underwent surgery, developed an MRSA wound infection, deteriorated after further surgery, and died on 20 August 2015. Concerns included failure to establish her MRSA history, lack of prophylactic Teicoplanin, absence of a post-operative wound care plan, inadequate evidence of wound inspection, and meaningless nursing documentation about the wound.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to inspect the surgical wound
Wider context from the report
“(4) There was no evidence of the surgical wound having been inspected by nursing staff or doctors between the 13th August and 25th August 2015 ”
Source location
Alwyn Ann Head · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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
Incorporate infection-status and wound-care documentation into the new nursing assessment and care-planning document.

Verbatim wording from the response
“• The new documentation will be incorporated into a new nursing patient assessment / care planning document which is due to be implemented in July 2016.”

Source location
A-head-Response
Page 2 · response
Published 23 March 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update tissue-viability policy and procedures with NICE guidance and post-operative surgical-wound management standards.

Verbatim wording from the response
“We are updating our tissue viability policy and associated standard operating procedures (SOPs) to include NICE guidance and standards for post-operative surgical wound management.”

Source location
A-head-Response
Page 2 · response
Published 23 March 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review wound-care documentation, care plans and wound-assessment standards.

Verbatim wording from the response
“Wound care documentation, care plans and wound assessment standards have all been reviewed. The wound care documentation will be incorporated into the new nursing assessment / care planning document in July 2016.”

Source location
A-head-Response
Page 2 · response
Published 23 March 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Present wound-care documentation and standards to safety and nursing quality forums and cascade them through directorates.

Verbatim wording from the response
“The documentation and standards will be presented to the Trust Patient Safety Group and the Nursing & Midwifery Quality Forum. Directorate representatives will be responsible for cascading the information through their Directorate.”

Source location
A-head-Response
Page 2 · response
Published 23 March 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Monitor compliance with wound-care policies and procedures through established assurance audits and governance forums.

Verbatim wording from the response
“Compliance with the policies and SOPs will be monitored as part of our established assurance audits. Results of audits are presented at Patient Safety Group which has responsibility for monitoring compliance in this area and the Nursing & Midwifery Quality Forum.”

Source location
A-head-Response
Page 2 · response
Published 23 March 2016
Open published response
14 Oct2015
Leicester City and South Leicestershire
Concerns raised1
1. Failure to report post-operative observations to medical staff when EWS is rising
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Provide continuous teaching for Clinical Management Group staff on interventional radiology procedures, complications, observation frequencies, complication recognition and escalation.
  Stated by University Hospitals of Leicester NHS TrustStated planned
2. Action
  Redesign the observation-frequency handover sheet by procedure type and require signatures from interventional radiology and receiving-ward nurses at the radiology theatre.
  Stated by University Hospitals of Leicester NHS TrustStated planned
3. Action
  Rewrite the EWS training package to clarify actions when scores are unreliable or require escalation, incorporating learning from the case.
  Stated by University Hospitals of Leicester NHS TrustStated in progress
AI-generated summary

Alan Tear · 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 Tear was receiving palliative treatment for cholangiocarcinoma and died after a biliary drain insertion. He died from an intraperitoneal bleed caused by a misplaced drain and peritoneal perforation. Concerns included missed post-operative observations, failure to report a rising EWS to medical staff, and unclear communication between the interventional radiology and nursing teams.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to report post-operative observations to medical staff when EWS is rising
Wider context from the report
“2. Post-operative observations were not reported to medical staff as required when the EWS was rising. ”
Source location
Alan Tear · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide continuous teaching for Clinical Management Group staff on interventional radiology procedures, complications, observation frequencies, complication recognition and escalation.

Verbatim wording from the response
“Additionally, as part of our wider learning, our Clinical Director for the Clinical Management Group (CMG) will, along with the Medical Lead for Imaging ensure that there is a continuous teaching session for CMG staff on the issue of Interventional Radiology for Surgical patients; describing the technique, complications, frequency of observation for each different procedure, identification of complications and escalation. This will have occurred before the end of December 2015.”

Source location
Response from University Hospitals of Leicester NHS Trust
Page 2 · response
Published 14 October 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Redesign the observation-frequency handover sheet by procedure type and require signatures from interventional radiology and receiving-ward nurses at the radiology theatre.

Verbatim wording from the response
“As a result of this inquest we will be redesigning the sheet which documents the required frequency of observations to be undertaken on the receiving ward. The sheet and required frequency will vary according to the type of the procedure performed. To optimise the hand over the sheet will be signed by the Interventional radiology nurse and receiving ward at the radiology theatre. Our Medical Lead for Imaging, in consultation with surgical colleagues, will have completed this work by the end of December 2015.”

Source location
Response from University Hospitals of Leicester NHS Trust
Page 2 · response
Published 14 October 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Rewrite the EWS training package to clarify actions when scores are unreliable or require escalation, incorporating learning from the case.

Verbatim wording from the response
“However we remain committed to improving our on-going education at the Trust on the EWS scoring tool. Our Interim Deputy Medical Director and Assistant Chief Nurse are currently rewriting the EWS training package and will use what occurred in this case to ensure that clinical staff are given clarity on the actions that they must take when there is either doubt as to the reliability of any particular EWS score or the EWS score is considered to require escalation. This work is due to be completed by the end of March 2016.”

Source location
Response from University Hospitals of Leicester NHS Trust
Page 3 · response
Published 14 October 2015
Open published response
27 Jan2015
Surrey
Concerns raised1
1. Failure to assess and monitor post operative fluid balance
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Implement national-standard Early Warning Score paperwork and provide recurring staff training on deterioration recognition and fluid-balance monitoring.
  Stated by Survey and Sussex NHS Healthcare NHS TrustStated completed
2. Action
  Provide Sepsis, Acute Kidney Injury and fluid-balance monitoring study days for ward nurses.
  Stated by Survey and Sussex NHS Healthcare NHS TrustStated in progress
3. Action
  Deliver ward-based teaching on patient assessment, acute kidney injury and fluid balance, with further sessions planned during 2015.
  Stated by Survey and Sussex NHS Healthcare NHS TrustStated in progress
1. Action
  Restart ALERT courses covering deterioration recognition, acute kidney injury and fluid-balance charts.
  Stated by Survey and Sussex NHS Healthcare NHS TrustStated completed
2. Action
  Start BEACH courses in April 2015, including fluid-balance monitoring training.
  Stated by Survey and Sussex NHS Healthcare NHS TrustStated planned
3. Action
  Conduct a Trust-wide audit of fluid-balance chart completion during 2015.
  Stated by Survey and Sussex NHS Healthcare NHS TrustStated planned
AI-generated summary

Susanna Geraty · 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

Susanna Geraty, a previously fit and well 75-year-old woman, died after developing acute renal failure and hyperkalaemic cardiac arrest five days after surgery for a fractured tibia and fibula. The principal concerns were inadequate assessment, monitoring and recording of postoperative fluid balance, failure to respond promptly to family concerns or recognise her deteriorating condition, and an investigation report’s failure to consider dehydration as a possible cause of the acute renal failure.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to assess and monitor post operative fluid balance
Wider context from the report
“1. Failure to assess, monitor and record post operative fluid balance. ”
Source location
Susanna Geraty · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement national-standard Early Warning Score paperwork and provide recurring staff training on deterioration recognition and fluid-balance monitoring.

Verbatim wording from the response
“Since this incident in 2012, SASH have implemented a number of improvements in the way that it records a patient’s fluid balance and in the way that it trains nursing staff with regards to recognising and acting on the identification of an acutely unwell patient and on monitoring post-operative fluid balance.”

Source location
2015-0026-Response-by-Surrey-Sussex-NHS-Trust
Page 2 · response
Published 27 January 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide Sepsis, Acute Kidney Injury and fluid-balance monitoring study days for ward nurses.

Verbatim wording from the response
“The CCOT have also started to provide a Sepsis/Acute Kidney Injury (AKI) and Fluid Balance Monitoring study day for ward nurses. The morning session consists of teaching sepsis theory followed by relevant case studies. The afternoon session concentrates on AKI theory and further case studies; the importance of fluid balance monitoring is also included in this session (appendix 3).”

Source location
2015-0026-Response-by-Surrey-Sussex-NHS-Trust
Page 2 · response
Published 27 January 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver ward-based teaching on patient assessment, acute kidney injury and fluid balance, with further sessions planned during 2015.

Verbatim wording from the response
“Ward based teaching sessions have been held on Newdigate and Leigh wards in January 2015 by CCOT to educate the staff on patient assessment, AKI and fluid balance. These sessions were well received and more sessions are planned for staff during the year.”

Source location
2015-0026-Response-by-Surrey-Sussex-NHS-Trust
Page 2 · response
Published 27 January 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Restart ALERT courses covering deterioration recognition, acute kidney injury and fluid-balance charts.

Verbatim wording from the response
“ALERT™ courses (a multi-professional course to train staff in recognising patient deterioration and act appropriately in treating the acutely unwell) started again within the Trust last year, which includes a section on AKI and fluid balance charts. BEACH (Bedside emergency assessment course for health care staff) courses will start in April 2015, which will also stress the importance of fluid balance monitoring.”

Source location
2015-0026-Response-by-Surrey-Sussex-NHS-Trust
Page 3 · response
Published 27 January 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Start BEACH courses in April 2015, including fluid-balance monitoring training.

Verbatim wording from the response
“ALERT™ courses (a multi-professional course to train staff in recognising patient deterioration and act appropriately in treating the acutely unwell) started again within the Trust last year, which includes a section on AKI and fluid balance charts. BEACH (Bedside emergency assessment course for health care staff) courses will start in April 2015, which will also stress the importance of fluid balance monitoring.”

Source location
2015-0026-Response-by-Surrey-Sussex-NHS-Trust
Page 3 · response
Published 27 January 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct a Trust-wide audit of fluid-balance chart completion during 2015.

Verbatim wording from the response
“There is a Trust wide audit planned for 2015, to assess the completion of the fluid balance chart to monitor compliance.”

Source location
2015-0026-Response-by-Surrey-Sussex-NHS-Trust
Page 3 · response
Published 27 January 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to inspect the surgical wound

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Failure to report post-operative observations to medical staff when EWS is rising

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to assess and monitor post operative fluid balance

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Actions described in response 5

Actions described in response 3

Actions described in response 6