Recurring concern

Failure to ensure clinical investigation results are reliably available, interpreted and acted upon

First to latest report 11 Sep 2013 — 25 Jun 2026

Reports that mention this concern
108
Times this concern has been raised
138
Stated actions linked to this concern
168

What this concern includes

Includes failures in the end-to-end process for managing clinical investigation results when the result is not reliably made available to, brought to the attention of, correctly checked or interpreted by, and acted upon by the responsible clinical team.

What is not included
  • Excludes failures concerning treatment monitoring or prescribing unless the assertion specifically concerns management of the resulting investigation result.
  • Excludes generic documentation, staffing, training or communication deficiencies that are not explicitly tied to the management of an investigation result.
  • Excludes administrative or test-ordering failures where no result-management deficiency is identified.
  • Excludes failures involving non-clinical items, equipment or processes unrelated to clinical investigation results.

Reports and published responses 108 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Essex

    AI-generated summary

    Chloe Anne Tapp · 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

    Chloe Anne Tapp, a 20-year-old with epilepsy and other medical conditions, suffered seizures and respiratory and cardiac arrest on 7 October 2021 and died in hospital on 8 October 2021. The principal concerns included delays transferring her to adult neurology, a telephone consultation despite her being non-verbal, an incorrect and inadequately documented medication tapering regime, and unanswered attempts to obtain clarification. Broader concerns were raised about staffing shortages, unsafe backlogs and difficulties responding to patients and carers within the neurology department.

    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 unsafe processes in investigation reporting and results access

    Wider context from the report

    “The consultant in question gave evidence of a very bleak picture of ongoing practice in the neurology department; a letter from all four consultants in that department had been sent to the Trust in July 2023, where patient care was described as ‘sub-optimal’, and numerous concerns were set out including: o Chronic staff shortages in respect of doctors, nurses and administrative staff within the neurology department o Substantial and unsafe backlogs for first and follow up appointments o Inability to answer, in a timely manner, the volume of phone calls, phone messages and emails from patients/carers raising queries. o The delays / ways in which investigations are carried out and reported, and the way in which clinical staff can access results. ”

    Source location

    Chloe Anne Tapp · 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

    Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.

    Verbatim wording from the response

    “Having considered your Report and the concerns raised, a GIRFT visit to Mid and South Essex NHS Foundation Trust has been arranged to review the specific situation within their Neurology department.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 March 2024

    Open published response

  2. Berkshire

    AI-generated summary

    Michael James NYE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Michael James Nye attended the Royal Berkshire Hospital with sepsis caused by a Streptococcus A skin and soft tissue infection, but was initially diagnosed with an upper arm DVT. His condition deteriorated and he suffered two cardiac arrests, with his death verified on 15 November 2022. Concerns included delays in blood tests, CT scanning, escalation to the Intensive Care Unit and prescribing antibiotics, as well as overcrowding, inadequate escalation arrangements and training needs concerning atypical sepsis.

    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 in notification of abnormal blood test results to clinicians

    Wider context from the report

    “a. Delays in blood tests being completed at night at the Royal Berkshire Hospital, and notification to clinicians on the Electronic Patient Record of abnormal results which are being reviewed. ”

    Source location

    Michael James NYE · 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

    Improve Emergency Department blood-result turnaround through process changes spanning booking, sample transport and laboratory processing.

    Verbatim wording from the response

    “A quality improvement project at the trust has focussed on the turnaround times for blood results being reported to ED. This focusses on shortening the time between ED booking in, and the blood result being returned and available to clinicians to inform decision-making. There are elements around processes in ED, elements in the transport of the sample to the lab, and also elements around the laboratory processes that we are working to improve.”

    Source location

    Response from Royal Berkshire NHS Foundation Trust
    Page 1 · response
    Published 22 February 2024

    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

    Upgrade the laboratory information management system to improve the reliability and connectivity of result reporting.

    Verbatim wording from the response

    “There is also an upgrade to the laboratory information management system (LIMS) taking place in April. Consequently, the reliability of result reporting is expected to improve, with much reduced connectivity challenges expected to follow this. Please see appendix A¹.”

    Source location

    Response from Royal Berkshire NHS Foundation Trust
    Page 1 · response
    Published 22 February 2024

    Open published response

  3. Teesside and Hartlepool

    AI-generated summary

    Kate Elizabeth O’Donnell · 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

    Kate Elizabeth O’Donnell underwent surgery on 16 March 2022 and was discharged the following day. She developed sepsis from the surgery, originating in her gut, and died at James Cook University Hospital on 23 March 2022. Principal concerns included inadequate surgical planning, failure to provide appropriate prophylactic antibiotics for the gastrointestinal surgery, insufficient postoperative vigilance and assessment before discharge, incomplete nursing records, and inadequate discharge information.

    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 review pre-surgery urine test results

    Wider context from the report

    “2. The consultant urologist did not know the results of pre-surgery urine test results and subsequently prescribed incorrect prophylactic antibiotics post urology surgery. ”

    Source location

    Kate Elizabeth O’Donnell · 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

    Implement an electronic patient record and scan historical records into it, including electronically signed, dated and timed clinical notes.

    Verbatim wording from the response

    “Appropriate surgical planning did take place but recording of decision making was poor and this was amplified with difficulties accessing notes in a timely manner. The Trust has now implemented an Electronic Patient Record system and has started to scan all historical records to link with this, which will prevent recurrence of this issue in future. The introduction of an electronic clinical noting system will also help prevent the other documentation errors that occurred in this case, referenced below, ensuring an electronic signature, date and time are linked to every note entry.”

    Source location

    Response from South Tees Hospitals
    Page 2 · response
    Published 25 January 2024

    Open published response

  4. Avon

    AI-generated summary

    Calogero Di Blasi · 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

    Calogero Di Blasi was referred for possible stomach and bowel cancer and underwent investigations including endoscopies and a CT scan. During a further endoscopy, a gastric varix was mistaken for an abnormal area and biopsied, causing a massive bleed; he died on 1 December 2022. The concerns included communication failures between specialist teams, insufficient timeframes for reviewing investigations on the urgent cancer pathway, and limitations in endoscopist training for recognising less common lesions.

    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 of specialty teams to communicate investigation information and share results in a timely manner

    Wider context from the report

    “(1) That one of the teams caring for Mr Di Blasi was completely unaware of the input from another specialty team, despite both referrals being made under the 2-week urgent referral pathway. The lack of communication between these teams meant that timely sharing of results did not occur. Even the very knowledge of the fact that a CT scan had taken place would have alerted the endoscopist to check those results, and it is likely that the second endoscopy would not have gone ahead. I understand this to be a national issue and is likely to apply to other investigations being carried out. ”

    Source location

    Calogero Di Blasi · Prevention of Future Deaths report
    Page 2 · 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

    Failure of 2-week urgent cancer pathway timeframes to include investigation reporting and referring-clinician review

    Wider context from the report

    “(2) That the reporting timeframes on the 2-week urgent cancer pathway referral does not take into account timeframes for reporting investigative procedures or subsequent review by the referring clinicians. ”

    Source location

    Calogero Di Blasi · 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

    Scope administrative review of patient lists to identify parallel clinical pathways before endoscopy and assess a possible pilot.

    Verbatim wording from the response

    “I asked ████████ and the witnesses to consider whether any further action could be taken to strengthen the pre-procedure checklist. I am advised that they have identified an additional potential change in practice. The Division of Surgery will undertake a scoping exercise to assess the feasibility of the administrative teams reviewing the patient list and identifying any patients who are on a parallel clinical pathway. The endoscopist would then be notified to review the electronic records and ICE and any relevant investigations before the procedure. Upon completion of the scoping exercise, the Division will consider whether a pilot may be offered for the endoscopy team.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 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

    Discontinue paper radiology reports from 1 May 2024.

    Verbatim wording from the response

    “Aligned to this, I have received an update in respect of the paper reports for radiology; these will be discontinued from 1 May 2024. Results will continue to be available via the ICE and PACS electronic reporting systems. As part of the transition away from paper results, the Trust plans to set up specialty specific reporting systems within our existing digital platforms.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 3 · response
    Published 21 November 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

    Set up specialty-specific radiology reporting systems within existing digital platforms.

    Verbatim wording from the response

    “Aligned to this, I have received an update in respect of the paper reports for radiology; these will be discontinued from 1 May 2024. Results will continue to be available via the ICE and PACS electronic reporting systems. As part of the transition away from paper results, the Trust plans to set up specialty specific reporting systems within our existing digital platforms.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 3 · response
    Published 21 November 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

    Launch a joint digital strategy to converge provider-collaborative IT systems and centralise clinical information digitally.

    Verbatim wording from the response

    “UHBW and NBT will shortly appoint a joint Chief Executive and Chair. The Chief Digital Information Officer has already been appointed across both Trusts and is in the process of launching a Digital Strategy, with the aim of converging the IT systems across the provider collaborative.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 4 · response
    Published 21 November 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

    Reformed cancer waiting-time standards by introducing the 28-day Faster Diagnosis Standard and consolidating nine reporting standards into three.

    Verbatim wording from the response

    “Since the death of Mr Di Blasi, NHS England and the Department have reformed cancer waiting time standards, following a clinically led review. This has replaced the two-week wait standard with the Faster Diagnosis Standard (FDS) for patients to get a cancer diagnosis or all-clear within 28 days of an urgent referral. The FDS moves focus away from process to deliver a clear clinical outcome – either diagnosing or ruling out cancer. This represents an improvement on the preceding 2-week wait standard, which was simply to “see a specialist” and addresses the coroners concerns, as the new standard takes into account times for reporting and reviewing diagnostic procedures. The reform also consolidated cancer standards from nine to three to reduce bureaucracy of reporting against a large number of standards.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 21 November 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

    Recruit radiologists to fill vacancies and increase reporting capacity.

    Verbatim wording from the response

    “Regrettably, in parallel with a number of organisations across the country, the Trust is not meeting this timeframe. The following mitigations have been put in place:”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 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

    Use outsourced radiology reporting to maximise reports completed within the target timeframe.

    Verbatim wording from the response

    “Regrettably, in parallel with a number of organisations across the country, the Trust is not meeting this timeframe. The following mitigations have been put in place:”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 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

    Provide locum radiology cover and additional reporting sessions for existing radiologists.

    Verbatim wording from the response

    “Regrettably, in parallel with a number of organisations across the country, the Trust is not meeting this timeframe. The following mitigations have been put in place:”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 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

    Scope increased radiographer resource to support radiologists.

    Verbatim wording from the response

    “• The Division is undertaking a scoping exercise to increase the resource of radiographers who could support the radiologists.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 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

    Add radiology turnaround times to the divisional risk register.

    Verbatim wording from the response

    “All of the above actions will increase reporting capacity and seek to enact the recommendations from the national guidance. In addition, the Radiology team have added a risk to the risk register around turnaround times. This will ensure that this remains a priority for the Division.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 2023

    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

    Local management and implementation of national policies and procedures is assigned to NHS England and the responsible Integrated Care Board.

    Verbatim wording from the response

    “In preparing this response, Departmental officials have made enquiries with NHS England. The matters of concern you raise relate to the local management and implementation of national policies and procedures. As such, I requested NHS England liaise with the North Somerset and South Gloucestershire Integrated Care Board (ICB) responsible for University Hospitals Bristol and Weston NHS Foundation Trust.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 21 November 2023

    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

    Existing clinician checks provide a robust process for identifying relevant investigations for patients on parallel clinical pathways.

    Verbatim wording from the response

    “As many patients are treated out of the region or in private or satellite institutions, the subsequent check by the clinician, through a discussion with the patient, provides another opportunity to identify relevant investigations, thereby ensuring there is a robust process in place.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 2023

    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

    The Faster Diagnosis Standard is considered to address concerns by including diagnostic reporting and review times within the cancer waiting-time standard.

    Verbatim wording from the response

    “Since the death of Mr Di Blasi, NHS England and the Department have reformed cancer waiting time standards, following a clinically led review. This has replaced the two-week wait standard with the Faster Diagnosis Standard (FDS) for patients to get a cancer diagnosis or all-clear within 28 days of an urgent referral. The FDS moves focus away from process to deliver a clear clinical outcome – either diagnosing or ruling out cancer. This represents an improvement on the preceding 2-week wait standard, which was simply to “see a specialist” and addresses the coroners concerns, as the new standard takes into account times for reporting and reviewing diagnostic procedures. The reform also consolidated cancer standards from nine to three to reduce bureaucracy of reporting against a large number of standards.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 21 November 2023

    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

    Radiology reporting cannot consistently meet the three-day cancer-pathway timeframe because of national staffing shortages, despite mitigation measures.

    Verbatim wording from the response

    “As you heard in evidence, there is, regrettably, a national shortage of Radiologists. I therefore envisage that the Secretary of State for Health may wish to add to the below response from the Trust.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 2023

    Open published response

  5. Inner West London

    AI-generated summary

    Kai TAKAGI · 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

    Kai Takagi attended Chelsea and Westminster Hospital on 11 June 2021 with severe stomach pain and left before an abnormal blood result, suggestive of acute pancreatitis, was received. The hospital planned to contact him but did not do so, and he was found dead at home on 14 June 2021; the stated medical cause of death was acute peritonitis from a perforated gastric ulcer. Concerns included inadequate tracking and follow-up of patients who leave with outstanding abnormal test results, reliance on oral handover, and incomplete implementation of a clinician-led review system.

    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 implement periodic clinician-led review of abnormal diagnostic results

    Wider context from the report

    “(4) That a periodic clinician led review of all abnormal blood results (and other test results), which the hospital has explored since I raised the matter in the hearing has not been fully implemented giving rise to the risk that patients who have left the hospital with potentially life-threatening conditions suggested by the tests may not be contacted urgently asking them to return thus increasing the risk of their untimely deaths. ”

    Source location

    Kai TAKAGI · 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

    Publish national standards for communicating diagnostic test results after hospital discharge.

    Verbatim wording from the response

    “In your Report you raised the concern that patients that leave Accident and Emergency (A&E) departments with outstanding diagnostic test results are not followed up and tracked. Both NHS England and the Royal Colleges have published national guidance and standards for following up on test results following discharge from hospital, please see below:”

    Source location

    Response from NHS England
    Page 1 · response
    Published 11 December 2023

    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

    Trusts are responsible for procedures following national guidance and for responding on handover arrangements and clinician-led review of abnormal blood results.

    Verbatim wording from the response

    “It is the responsibility of Trusts to ensure that they have the necessary procedures and arrangements in place to follow national guidance. It will also be for the Trust to comment on your concerns surrounding their handover arrangements and the clinician led review into abnormal blood results. NHS England notes that you have also addressed your Report to Chelsea and Westminster Hospital. We will carefully consider their response to you which we have asked to be sighted on.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 11 December 2023

    Open published response

  6. East London

    AI-generated summary

    Claire Twinn · 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

    Claire Twinn, a 47-year-old woman with Down’s syndrome, severe learning disability, and complex heart and lung conditions, became unwell and attended hospital with low oxygen saturations and symptoms including cough, sickness, and diarrhoea. She was diagnosed with suspected bilateral pneumonia, discharged on oral antibiotics, and found deceased by her family the following morning. The principal concerns were that she was discharged rather than admitted for monitoring and oxygen therapy, reasonable adjustments and specialised learning disability nursing input were not provided, safety-netting advice was not recorded, and the chest X-ray report was delayed.

    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 in reporting radiological chest x-rays

    Wider context from the report

    “4. A radiological report of the chest x-ray taken on 15th December 2023 was not reported until 25th December 2023. ”

    Source location

    Claire Twinn · 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

    Increase Emergency Department imaging-reporting radiologists and radiographers to near-full capacity.

    Verbatim wording from the response

    “Since the time of the incident, we have increased our reporting radiologists and radiographers to near full capacity and are in the process of recruiting further reporters in order to reduce the turnaround time. At present, we insource our plain films to all reporters and outsource ones that may be reaching the expected time frame.”

    Source location

    Response from Barts Health NHS Trust
    Page 2 · response
    Published 30 October 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

    Recruit further imaging reporters to reduce reporting turnaround times.

    Verbatim wording from the response

    “Since the time of the incident, we have increased our reporting radiologists and radiographers to near full capacity and are in the process of recruiting further reporters in order to reduce the turnaround time. At present, we insource our plain films to all reporters and outsource ones that may be reaching the expected time frame.”

    Source location

    Response from Barts Health NHS Trust
    Page 2 · response
    Published 30 October 2023

    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

    The chest radiograph was reported within the department’s ten-working-day timeframe, despite being completed outside normal working hours.

    Verbatim wording from the response

    “4. A radiological report of the chest x-ray taken on 15th December 2022 was not reported until 25th December 2022.”

    Source location

    Response from Barts Health NHS Trust
    Page 2 · response
    Published 30 October 2023

    Open published response

  7. North Yorkshire and York

    AI-generated summary

    Carole MCQUINN · 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

    Carole MCQUINN underwent pancreatic surgery in February 2022 and subsequently experienced pancreatic leakage, abdominal collections and prolonged hospital treatment. After discharge without a discharge note, medication or follow-up appointment, concerns about infection were not adequately recorded or escalated, and a positive swab result was not reviewed until several days later. She was later admitted with suspected intra-abdominal sepsis and was found unresponsive in hospital; the inquest concluded that she died from a pulmonary embolism likely related to post-operative infection, inflammation and immobility.

    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 ensure swab results are reviewed

    Wider context from the report

    “2. Trust staff interacting with the deceased and her daughter regarding infection concerns arising in the post-discharge period between 21/4/22 and 3/5/22 made no records of the same. Nursing staff were shown photographs of the deceased's drain site, and issued stoma bags and a swab to her daughter for suspected infection, but did not flag this development to the treating team or make arrangements for the results of the swabs to be reviewed. No clinical observations of the deceased were recorded when she attended the hospital on 3/5/22. The swab result did not come to anyone's attention or get reviewed until the deceased's daughter flagged the issue to staff on 3/5/22. These omissions led to missed opportunities for earlier assessment and treatment of the deceased. ”

    Source location

    Carole MCQUINN · 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

    Require staff to record recent post-discharge contacts, advice, investigations and clinicians in PPM+, and forward review requests to outpatient teams.

    Verbatim wording from the response

    “The problems that arose in this case have been discussed at ward meetings. Staff have been instructed that all contact with recently discharged patients and their relatives must be recorded on the Trust’s electronic case record system PPM+ for the first 7 days after discharge at least. Notes made must include details of advice given, any investigations undertaken or arranged and the clinicians involved. Staff have also been informed that requests for advice or review should be forwarded to the outpatient team to facilitate early face to face assessment, coordination of any additional investigations, formal review of results and appropriate communication with the patient and family members afterwards.”

    Source location

    Response from Leeds Teaching Hospitals NHS Foundation Trust
    Page 3 · response
    Published 21 July 2023

    Open published response

  8. Birmingham and Solihull

    AI-generated summary

    Mohammed Khalid HUSSAIN · 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

    Mohammed Khalid HUSSAIN was found collapsed on the bathroom floor at his home on 28 November 2022 and was confirmed deceased shortly afterwards. The medical cause of death was determined to be sudden cardiac death in schizophrenia. Concerns included inadequate systems for monitoring, communicating and acting on high clozapine levels and medication changes, as well as deficiencies in internal investigation, understanding of clozapine and pharmacy resourcing.

    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 highlight high clozapine results in routinely used clinical notes

    Wider context from the report

    “3. How to record high clozapine levels: The clozapine and nor clozapine levels are recorded in the pharmacy section of the records. There was no system for highlighting high clozapine results in the rio notes which are routinely used by all clinicians. ”

    Source location

    Mohammed Khalid HUSSAIN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Existing ICE access, abnormal-result indicators and pharmacy reporting provide the strongest safeguards for recording and responding to high clozapine levels.

    Verbatim wording from the response

    “All blood test results are made available to staff in the ICE system, which is provided to us by our pathology service provider. This system is used both for ordering tests and reviewing results. It is accessed from within Rio and in patient context, so all staff have ready access to results. In common with most other systems, abnormal results are indicated within the system along with the normal reference range.”

    Source location

    Response Birmingham and Solihull Mental Health NHS Foundation Trust
    Page 2 · response
    Published 18 July 2023

    Open published response

  9. Lincolnshire

    AI-generated summary

    Elizabeth Oluwatofunmi AGBEJIMI · 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

    Elizabeth Oluwatofunmi AGBEJIMI died on 27 June 2021 at Lincoln County Hospital following multiple falls identified by the pathologist as a direct cause of death. Concerns were raised that a venous blood gas sample showing significant respiratory abnormal acidosis was not further investigated, with the deceased dying two weeks later of a respiratory condition; the report questioned whether this involved training or communication.

    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 investigate a significantly abnormal respiratory acidosis blood gas result

    Wider context from the report

    “████████ gave evidence that following a venous blood gas sample undertaken on 12th June 2021 which showed a significant respiratory abnormal acidosis reading but no further investigation was undertaken. The deceased died 2 weeks later of a respiratory condition. Is this a training/communication issue? ”

    Source location

    Elizabeth Oluwatofunmi AGBEJIMI · 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

    Require ED clinicians acknowledging blood gas results to document abnormalities requiring management and the planned further management.

    Verbatim wording from the response

    “1. Ensure better documentation of the identification of the abnormalities on the blood gas results”

    Source location

    Response from United Lincolnshire Hospitals NHS Trust
    Page 2 · response
    Published 10 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

    Have clinical audit teams in both ULHT departments audit blood gas results and documentation to assess whether the learning and actions are embedded.

    Verbatim wording from the response

    “In order to assure that these processes have been embedded, the clinical audit team in both ULHT departments will undertake an audit of blood gas results and the documentation in them to review the learning and actions have been embedded.”

    Source location

    Response from United Lincolnshire Hospitals NHS Trust
    Page 3 · response
    Published 10 July 2023

    Open published response

  10. 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

    Delays in urgent blood sample delivery and reporting

    Wider context from the report

    “10. Blood samples taken at 8.02 am were not delivered to the laboratory until 9.06 am and then not reported on until 10.21 am as they had not been marked as ‘urgent’. This also reflects a failure to appreciate the gravity of the situation. ”

    Source location

    Carol Ann Hatch · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026