Recurring concern

Failure to reliably communicate clinically significant patient observations to medical staff

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First reported 2 Apr 2014•Latest report 27 Oct 2023

Definition

What this concern includes

Includes failures of the dedicated process for recognising and communicating clinically significant patient observations or changes to medical staff, including abnormal temperature, rising early warning scores and other observations requiring medical review.

Not included

  • Excludes failures to perform or obtain the observation when the observation was not completed; those belong to patient-observation performance or monitoring concerns.
  • Excludes failures limited to recording, charting or preserving observations when communication to medical staff was not deficient.
  • Excludes failures to assess, treat or act on an observation after it was reliably communicated.
  • Excludes generic communication or staffing deficiencies without a direct patient-observation communication or escalation failure.
  • Excludes non-patient observations and observations not requiring communication to medical staff.
Reports
16

Distinct published reports

Individual concerns
17

A report can raise multiple concerns

Date range
2014–2023

First to latest report issue date

Stated actions
28

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

General Medical Council2
Nursing and Midwifery Council2
University Hospitals Sussex NHS Foundation Trust2
Amberley Hall Care Home1
Athena Care Homes (UK) Limited1
Belmarsh Prison1
Care Quality Commission1
Cwm Taf Morgannwg University Local Health Board1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
Great Western Hospitals NHS Foundation Trust1
Holy Cross Hospital1
Liverpool University Hospitals NHS Foundation Trust1
NHS Cheshire and Merseyside Integrated Care Board1
NHS England1
Public Health England1

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.

  1. Norfolk

    AI-generated summary

    Geoffrey Alan WHATLING · 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

    Geoffrey Alan Whatling entered Amberley Hall Care Home for rehabilitation and later became unwell, with deteriorating NEWS2 scores leading to hospital admission on 10 April 2023. He died on 26 April 2023, with the medical cause of death recorded as infective exacerbation of chronic obstructive pulmonary disease, with frailty and old age. Concerns included incomplete food and fluid records, failures to call emergency services when required, inadequate observation frequency, and gaps in care-record documentation and follow-up.

    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 communicate NEWS2 scores to the 111 call taker

    Wider context from the report

    “3. The evidence so far revealed is that 111 call taker was not made aware Mr Whatling had scored NEWS2 7. ”

    Source location

    Geoffrey Alan WHATLING · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. West Yorkshire Eastern

    AI-generated summary

    Carol Ann Hatch · 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

    Carol Ann Hatch underwent repeat hiatus hernia surgery at a private hospital on 31 August 2022 and became unwell overnight. She was transferred to an NHS hospital, treated for septic shock and organ failure for six weeks, and died on 18 October 2022. The report identifies concerns about overnight monitoring, escalation, staffing competence, record-keeping, and delays in investigations and treatment; evidence at the Inquest indicated that the failings contributed to her death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to alert senior clinicians to unexpected patient deterioration

    Wider context from the report

    “1. Mrs Hatch’s condition deteriorated markedly during the night of 31 August/1 September 2022 (some hours after surgery). Neither the surgeon nor the anaesthetist were alerted to this unexpected deterioration. The Surgeon only became aware of the position when he contacted the hospital and came in around 7 am. ”

    Source location

    Carol Ann Hatch · 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

    Provide NEWS refresher training to relevant colleagues and conduct regular audits of NEWS compliance.

    Verbatim wording from the response

    “In addition to addressing NEWS training with agency staff, the hospital have ensured a NEWS update refresher has been provided to all relevant colleagues and have conducted regular audits to provide assurance in relation to compliance.”

    Source location

    Response from Spire Healthcare Limited
    Page 4 · response
    Published 7 July 2023

    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 training to RMOs on recognising deteriorating patients and signs of gastric perforation.

    Verbatim wording from the response

    “This matter was recognised in the RCA, has been discussed with the RMO and there is a plan in place for training to be delivered to RMOs on recognising signs of a deteriorating patient and recognising signs of gastric perforation. In addition, Spire has received confirmation that the RMO has undertaken a recent appraisal. We refer the Coroner to evidence file relating to the RMO which includes evidence of action taken in relation to this concern.”

    Source location

    Response from Spire Healthcare Limited
    Page 5 · response
    Published 7 July 2023

    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

    Introduce deteriorating-patient stickers for clinical use.

    Verbatim wording from the response

    “ADDITIONAL ACTIONS EVIDENCE”

    Source location

    Response from Spire Healthcare Limited
    Page 11 · response
    Published 7 July 2023

    Open published response

  3. Surrey

    AI-generated summary

    Richard Scott-Powell · 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

    Richard Scott-Powell, aged 61, suffered a spinal cord injury after a fall at home in March 2020 and later died from COVID-19 pneumonia at Holy Cross Hospital on 18 January 2021. The principal concerns were the lack of recorded escalation of high NEWS2 scores and abnormal vital signs, incomplete recording of observations, and uncertainty about whether appropriate policies and training were in place for taking, recording and escalating vital observations.

    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 escalate NEWS2 scores and abnormal vital observations

    Wider context from the report

    “The court heard evidence that following Mr Scott-Powell’s positive COVID-19 test on 11 January 2021 a NEWS2 Observation Chart was commenced on 13 January 2021. On that day he initially had a NEWS2 score of 10 and subsequently a NEWS2 score of 5. There is no clear evidence in the hospital records to show that these scores prompted an increased level of frequency of observations or that they were escalated, whether that be to Mr Scott-Powell’s GP or otherwise. Thereafter, there are no further NEWS2 charts in Mr Scott-Powell’s records, albeit some of his vital signs are recorded in the daily notes. On a number of occasions, the notes only record that ‘vital signs are okay’ without specifying what the vital signs actually were. In respect of some of the vital signs that were recorded, Dr ████████, a GP at Grayshott Surgery which is the GP Surgery for patients at Holy Cross Hospital, gave evidence that some of them fell outside normal or expected parameters. Again, there is no evidence in the notes to show that these observations were escalated prior to Mr Scott-Powell’s death. Given Mr Scott-Powell’s pre-existing conditions and vulnerabilities the Court was not persuaded, on the balance of probabilities, that any escalation would have resulted in treatment, which would have materially improved Mr Scott-Powell’s clinical progress. 1. There is no recorded escalation of Mr Scott-Powell’s NEWS2 scores on 13 January 2021; 2. During the period from 14 January 2021 onwards, only some of his vital signs are recorded, some of which fall outside normal parameters. There is no recorded escalation of these observations in the record. 3. During the period from 14 January 2021 onwards, a number of entries record that his vital signs were okay without detailing the actual outcome of those observations. The Coroner is concerned this may not be a safe practice in that it makes it difficult for the clinical team to track progress and identify any trends. Dr ████████, a Consultant in Rehabilitation Medicine at Holy Cross Hospital and Dr ████████, GP, both attended Court to give evidence and whilst they did their best to assist the Court on these matters, it remains unclear to the Court as to whether there are sufficient and appropriate policies are in place, which are well understood by the staff, in relation to the taking, recording and escalation of vital observations at Holy Cross Hospital. Accordingly, the Coroner considers that a review of these matters should be carried out to identify whether additional policies/procedures and or/training is required. ”

    Source location

    Richard Scott-Powell · Prevention of Future Deaths report
    Page 4 · 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

    Adopt and implement the Managing a Deteriorating Patient policy, including monitoring and escalation guidance and regular NEWS2 baseline collection.

    Verbatim wording from the response

    “• have written a policy on ‘Managing a Deteriorating Patient’, which includes a decision tree for monitoring and escalation. The policy proposes collecting regular NEWS2 baseline data for each Holy Cross patient, taking into account that many patients will routinely fall outside of the normal range. The draft policy has been reviewed by our Consultant in Rehabilitation Medicine and by the lead duty doctor to Holy Cross (from Grayshott surgery), ahead of adoption by our Clinical Governance Medical Research and Ethics Committee on 25th July. Following its implementation, the policy will be subject to review and evaluation. Staff will receive training on the policy.”

    Source location

    Response from Holy Cross Hospital
    Page 2 · response
    Published 27 April 2022

    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

    Repeat clinical decision-making, patient-risk, NEWS2 and sepsis training for relevant ward staff.

    Verbatim wording from the response

    “Training (clinical decision making / patients at risk) - As part of a wider range of learning and development courses, training is provided to the ward team to facilitate clinical decision-making and escalation as follows: Clinical Decision Making (Registered Nurses), Identifying Patients at Risk (Health Care Assistants), NEWS2 (Registered Nurses and HCAs) and Sepsis (Registered Nurses and HCAs). The first two courses are in-house, with NEWS2 and Sepsis being online courses (containing standard methodologies/protocols). We are in the process of repeating training in these areas for all relevant staff.”

    Source location

    Response from Holy Cross Hospital
    Page 1 · response
    Published 27 April 2022

    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

    Train staff on the Managing a Deteriorating Patient policy after implementation.

    Verbatim wording from the response

    “• have written a policy on ‘Managing a Deteriorating Patient’, which includes a decision tree for monitoring and escalation. The policy proposes collecting regular NEWS2 baseline data for each Holy Cross patient, taking into account that many patients will routinely fall outside of the normal range. The draft policy has been reviewed by our Consultant in Rehabilitation Medicine and by the lead duty doctor to Holy Cross (from Grayshott surgery), ahead of adoption by our Clinical Governance Medical Research and Ethics Committee on 25th July. Following its implementation, the policy will be subject to review and evaluation. Staff will receive training on the policy.”

    Source location

    Response from Holy Cross Hospital
    Page 2 · response
    Published 27 April 2022

    Open published response

  4. Brighton and Hove

    AI-generated summary

    Ioannis AVGOUSTI · 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

    Ioannis Avgousti died after an episode involving documented allergy to Co-Amoxiclav, during which the medication was prescribed and administered. The report identified concerns about failure to follow allergy guidance, inadequate communication, failure to act on elevated NEWS observations or escalate care, and staffing pressures during the relevant shift.

    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 act on NEWS observations and escalate deteriorating patients

    Wider context from the report

    “(2) On the 6th October 2018 although the hospital had noted that he was allergic to Co-Amoxiclav and although the paper medication notes noted that fact he was written up for that medication and it was administered to him. I saw evidence of a poorly documented, from the point of view of time, NEWS observation. Although at the top of the chart there were the numbers 2 0 (20) I found on the balance of probabilities that set of observations had more likely been taken at about 20:10 or 20:15 hours. The observations were added up to 9. In fact the total was 13. NEWS is a tool to ensure that the deteriorating patient is recognised and given help and escalated, if appropriate, to Intensive Care. This set of observations was not acted on in accordance with the directions and no escalation was made. There should have been a MET call then i.e., at around 20:15 hours to a specialist registrar (there was one on duty) If this call had been made and if the appropriate doctor had been called to see Mr. Avgousti it is possible that although the sepsis protocol would I believe have been implemented, it would have been realised that he had an allergy to Co-Amoxiclav and he would have been given an appropriate alternative. Whilst I cannot say categorically that this would have been the case I believe it is highly likely. NEWS is an important tool and should not be ignored as it was on Vallance Ward on the night of the 6th October 2018. ”

    Source location

    Ioannis AVGOUSTI · 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

    Expand the Critical Care Outreach service to support immediate escalation from electronic NEWS scores.

    Verbatim wording from the response

    “Critical Care Outreach service, of which we are expanding, so escalation will be immediate rather than reliant on staff on the ward calculating the scores and putting out a MET call.”

    Source location

    2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
    Page 3 · response
    Published 14 June 2019

    Open published response

  5. Liverpool and the Wirral

    AI-generated summary

    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.

    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 escalate and convey the severity of deterioration to the Critical Care Team

    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
    Page 3 · concerns

    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
    Page 3 · concerns

    Open source report

  6. Norfolk

    AI-generated summary

    KIRSTY ELIZABETH TOLLEY · 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

    Kirsty Elizabeth Tolley had several health problems and was admitted to Queen Elizabeth Hospital with severe anaemia and a high temperature. She was later found unresponsive in bed on 19 November 2017 and was declared dead despite resuscitation. Concerns included blood tests not being carried out daily as required, incomplete Early Warning Score monitoring, and a lack of documented escalation or additional observations when scores reached 3; the medical cause of death was unascertained.

    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 escalate EWS scores of 3 for medical review and increased observations

    Wider context from the report

    “(3) Evidence was heard that if EWS reaches 3, then this should be escalated to a doctor who should review the patient and set a plan. Observations should be increased to 4 times per hour with further review. The EWS reached 3 on 4 occasions (including the occasion when the EWS was not completed in the records – 17 February) and there is no evidence that any additional action was taken. In particular on the 17 February no observations/EWS for over 17 hours. ”

    Source location

    KIRSTY ELIZABETH TOLLEY · 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

    Provide staff with support to understand and use the current escalation system.

    Verbatim wording from the response

    “The staff, both nursing and medical, working in that clinical area have received support to ensure that they understand and are able to use the current escalation system.”

    Source location

    2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
    Page 2 · response
    Published 1 July 2018

    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

    Implement NEWS2 with new documentation, training and escalation procedures, supported by communications and a November 2018 go-live.

    Verbatim wording from the response

    “The Trust has therefore decided to bring forward plans to adopt the National Early Warning system (NEWS2) that is mandated across the NHS from April 2019 and will implement this on November 1st 2018.”

    Source location

    2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
    Page 2 · response
    Published 1 July 2018

    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

    Appoint a NEWS2 Champion.

    Verbatim wording from the response

    “May 16 Appointment of NEWS2 Champion”

    Source location

    2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
    Page 2 · response
    Published 1 July 2018

    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 ongoing audits of NEWS2 documentation and escalation.

    Verbatim wording from the response

    “This will be followed by an ongoing audit to ensure appropriate documentation and audit of escalation.”

    Source location

    2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
    Page 2 · response
    Published 1 July 2018

    Open published response

    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

    Widespread retraining on older escalation procedures will not occur before NEWS2 implementation because it could cause confusion.

    Verbatim wording from the response

    “The Trust has therefore decided to bring forward plans to adopt the National Early Warning system (NEWS2) that is mandated across the NHS from April 2019 and will implement this on November 1st 2018.”

    Source location

    2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
    Page 2 · response
    Published 1 July 2018

    Open published response

  7. South Wales Central

    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.

    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 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
    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

    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
    Page 1 · response
    Published 7 June 2018

    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

    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
    Page 1 · response
    Published 7 June 2018

    Open published response

  8. Wiltshire and Swindon

    AI-generated summary

    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.

    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

    Delays and unclear responsibility for timely clinician escalation from care plans

    Wider context from the report

    “1. Expectations of F1/F2 doctors – personally I have no experience of training or being involved in the training of F1/F2 doctors and my only experience in respect of which I do not see a fundamental dissimilarity is in relation to trainee lawyers or in particular training solicitors in respect of whom I have been involved in their training during my professional career. F1/F2’s when appointed are given a provisional licence to practice at the end of their medical degree. Trainee solicitors are again allowed to work under supervision following the completion of their professional examinations which for example can be a degree combined with a post graduate legal practice course. My experience in relation to trainee solicitors is that the expectations of what they realistically can do is at a low level and having heard from ████████ from whom I was told that it is not fundamentally different in respect of F1/F2 doctors. The Great Western Hospital of course is a teaching hospital and therefore in relation to the training of doctors it is often, I imagine, imperative that what may seem obvious to you or I perhaps needs to be spelled out to those trainees who may be entering the working environment in their chosen career area for the very first time. In relation to Dr Marshall's case I was concerned that the evidence revealed that ████████ had not contacted ████████ until the bleeped him at 0513 despite the care plan in relation to a seriously ill patient who at the time was peripherally shutting down in respect of which both ████████ and ████████ had recognised the seriousness of the condition as to why ████████ was not contacted sooner. There had been a 3 point increase in his NEWS score yet there appeared to be a delay in contacting ████████ to a degree and significant delay in contacting ████████. No instruction had been given to nursing staff to bleep the relevant doctors and I am concerned as to whether or not in respect of all doctors that the point needs to be emphasised that whoever records the care plan on the notes at doctor level should have the responsibility of bleeping another clinician in a timely fashion unless the notes clearly indicate that that responsibility has been given to somebody else and then the notes to identify when and to whom that instruction was given. ”

    Source location

    Jeremy Michael Holt · 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

    Update the junior surgical doctors’ handbook to cover delegation responsibilities and documented follow-up plans.

    Verbatim wording from the response

    “The Trust has considered your view and is of the belief there is no single solution to this. The omissions most likely stemmed from human factors rather than a system failing. Therefore a multidisciplinary approach is being taken strengthening personal accountability including updates to a handbook, simulation training and Adult Basic Life Support training.”

    Source location

    2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
    Page 2 · response
    Published 18 December 2017

    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 simulation training to emphasise clear communication and delegation of responsibility.

    Verbatim wording from the response

    “The Trust also has plans to update simulation training and the Adult Basic Life Support training. Simulation training consists of interactive training sessions relating to real life clinical situations. The Trust plans to incorporate the importance of clarity of communication (including delegating responsibility for tasks) into these sessions. Simulation training sessions which have already been held, have been found to be highly effective in developing the skills of staff.”

    Source location

    2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
    Page 2 · response
    Published 18 December 2017

    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 and update mandatory Adult Basic Life Support training with emergency and non-emergency delegation scenarios and documentation requirements.

    Verbatim wording from the response

    “The Adult Basic Life Support is annual mandatory face to face training for clinical staff. There is a plan to review the training provided and to update this to include scenario training on what to do in an emergency situation specifically in relation to the delegation of tasks. There is a plan to also include a section on what to do in a non-emergency situation and the importance of documenting delegation details.”

    Source location

    2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
    Page 2 · response
    Published 18 December 2017

    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

    Install electronic observations with automated, sequential escalation alerts to doctors and implement the system Trust-wide.

    Verbatim wording from the response

    “In the New Year the Trust will be installing an electronic observations IT system. For this the Trust is developing clear algorithms to enable automatic escalation to the doctors, this will be on a loop so if for example the F2 doctors do not respond, this will be escalated to the registrars and will continue through the doctor ranks up to Consultant until someone responds to the escalation alert. I have enclosed the high level roll out plan, you will see we aim to have electronic observations implemented Trust wide by May 2018.”

    Source location

    2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
    Page 3 · response
    Published 18 December 2017

    Open published response

  9. Brighton and Hove

    AI-generated summary

    Diana Maxine RITCHIE · 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

    Diana Maxine Ritchie was recovering from major surgery when she deteriorated overnight on 5–6 March and suffered a cardiac arrest at around 12.20 hrs on 6 March. Concerns included missed opportunities to escalate care in response to raised NEWS scores, inaccurate or potentially delayed observations, and failures in the use of NEWS across the Trust.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to report raised NEWS scores to doctors or critical care outreach

    Wider context from the report

    “(2) That there were missed opportunities to escalate Mrs Ritchie's treatment arising from raised NEWS scores where there was no report of those raised scores either to the doctors on the ward or to the critical care outreach team. There were eight different NEWS scores taken between 06.30 on the 6th and 11.15 on the 6th. On two of them the scoring was inaccurate (one was scored 2 points too high and the other was scored 2 points too low). One of them scored at 4 but the remainder scored at 5 and above. As I say, none of them resulted in a call to critical care outreach or to the ward SHO. ”

    Source location

    Diana Maxine RITCHIE · 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

    Improve ward staff familiarity with National Early Warning observations, scoring and escalation through reflection and additional training.

    Verbatim wording from the response

    “I recognise, as does the Trust's Interim Chief Nurse, that accurate completion and scoring of observations on the National Early Warning charts, and appropriate escalation, is very important. In the light of these events, considerable action has been taken on the ward concerned (in conjunction with their matron) to ensure that the individuals directly caring for Mrs Ritchie, as well as the rest of the ward team, are fully familiar with what is expected of them. They have reflected carefully on this, as well as attending specific additional training since these sad events to improve their knowledge and skills. The ward action plan is being presented to the monthly adult meeting for women's services, as well as feedback being taken to the safety and quality meeting for wider learning.”

    Source location

    2016-0296-Response-by-Brighton-and-Sussex-University-NHS-Trust
    Page 1 · response
    Published 18 August 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

    Disseminate National Early Warning System safety guidance to all staff through the weekly Spotlight on Safety message and Patient Observation Policy link.

    Verbatim wording from the response

    “In order to extend this learning more widely, I used the Spotlight on Safety, in my weekly message to all staff, to focus on NEWS, saying - among other things - “it is vital that NEWS scores are calculated correctly and acted on appropriately if we are to provide safe care for our patients” and providing a direct link to the Trust's Patient Observation Policy.”

    Source location

    2016-0296-Response-by-Brighton-and-Sussex-University-NHS-Trust
    Page 2 · response
    Published 18 August 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

    Circulate a monthly patient-safety bulletin highlighting recognition and escalation of care for deteriorating patients.

    Verbatim wording from the response

    “The Trust's Patient Safety team sends a “Patients 1st” bulletin each month to all staff. This uses a fictionalized story to draw attention to things that may go wrong and sets out good practice. Since the death of Mrs Ritchie, such a bulletin has been circulated, which focused on the recognition and appropriate escalation of care for a deteriorating patient.”

    Source location

    2016-0296-Response-by-Brighton-and-Sussex-University-NHS-Trust
    Page 2 · response
    Published 18 August 2016

    Open published response

  10. Inner North London

    AI-generated summary

    Margaret Emily TUCK · 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

    Margaret Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

    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

    Delay in escalating falls to the responsible consultant

    Wider context from the report

    “5. The consultant in charge of Mrs Tuck’s care did not learn of the 15 October fall until 17 October. It seems that the junior doctors on her ward did not bring this to her attention. Mrs Tuck’s nephew, however, was gravely concerned to find his auntie unable to communicate, and brought this to the attention of the consultant. The consultant asked him “What do you want me to do, scan her brain?” and he replied “I think that would be a very good idea”. Hence a CT scan was conducted on the afternoon of 17 October. ”

    Source location

    Margaret Emily TUCK · Prevention of Future Deaths report
    Page 3 · 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

    Deliver multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.

    Verbatim wording from the response

    “3. Our Nurse Educator has been instrumental in setting up and delivering a new multi-disciplinary training programme around important issues, that includes falls prevention awareness and post falls care. As part of the Band 7 role regular assessment during the shift of care planned and delivered, is undertaken. All of our medical staff, including FY1’s, are invited to participate. Falls prevention and awareness is also included in the FY1 mandatory education programme. With the increased presence of Band 6 and 7 nurses on each shift all the clinical staff now have a first contact who they can handover important issues to, even when the named nurse is not on the ward. There are now four multidisciplinary board / handover meetings per 24-hours and these are focussed around patient safety and handover.”

    Source location

    2016-0273-Response-by-Barths-Health-NHS-Trust
    Page 3 · response
    Published 26 July 2016

    Open published response
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Data last updated 7 September 2026