21 Feb 2025 Lady Lola Kay Crouch · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to follow up potential malignancy findings View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Mid and South Essex NHS Foundation Trust
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Lady Lola Kay Crouch · 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
Lady Lola Kay Crouch died at Broomfield Hospital on 26 February 2023 from multi-organ failure due to small bowel obstruction associated with leiomyosarcoma of the small intestine and abdominal adhesions. A December 2022 CT finding suggestive of malignancy was not followed up or communicated to her, and it was not included in her later hospital history. The report also identifies delayed medical review overnight because of doctor staffing levels.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to follow up potential malignancy findings
Wider context from the report “(1) Lady Lola was not informed of the findings of potential malignancy from a CT scan in December 2022. This was not followed up and was then not given as part of the history when Lady Lola attended hospital in February 2023.
” Source location Lady Lola Kay Crouch · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The presentation and symptom resolution were more consistent with adhesive than malignant small bowel obstruction, making malignancy an unexpected outcome.
Verbatim wording from the response “I am advised by my surgical colleagues that presentations to the Emergency Department (ED) with signs and symptoms of bowel obstruction, particularly small bowel obstruction, have a variety of differential diagnoses. As in Lady Lola’s case, with a background of multiple previous complex open operations, adhesions are the leading cause of small bowel obstruction.” Source location Response from Mid & South Essex NHS Trust
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23 Dec 2024 William Charles Hare (Bill) · Prevention of Future Deaths report Essex
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Concerns raised 1
Delays in making CT scan results available View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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William Charles Hare (Bill) · Prevention of Future Deaths report
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Report summary
William Charles Hare (Bill) presented with abdominal and left loin pain in November 2022 and was subsequently diagnosed with metastatic urothelial cancer. He died in a hospice on 23 January 2024 after delays in diagnosis and treatment, including delays in biopsy, specialist review, MDT consideration, hospital transfer and scan results. The report identified systemic and procedural errors and ineffective coordination between Basildon and Southend Hospitals as substantive concerns.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in making CT scan results available
Wider context from the report “vii. A final delay occurred in the results of a CT scan , the results of which were not available until 15 January . By this time, the cancer had spread throughout Bill’s body and became untreatable.
” Source location William Charles Hare (Bill) · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use one comprehensive patient-tracking system across hospital sites to monitor cancer pathways, diagnostic reporting, timescales and required escalations.
Verbatim wording from the response “We now have one comprehensive patient tracking system for all hospital sites providing a centralised monitoring for all cancer patients and their progress through the cancer pathway.” Source location Response from Mid and South Essex NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Weekly specialist MDT meetings and centralised tracking are considered sufficient to prevent delays in scan review and treatment planning.
Verbatim wording from the response “We are not experiencing any delays between scans and the MDT review and patient clinics to review results are happening, and within the timescale prescribed within the cancer pathway.” Source location Response from Mid and South Essex NHS Foundation Trust
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12 Nov 2024 Lisa Gale · Prevention of Future Deaths report Avon
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Concerns raised 2
Failure of urgent liver function test reporting thresholds to account for pregnancy-specific conditions View source Failure to communicate grossly abnormal liver function test results from laboratory staff to clinical staff View source
Linked responses
Bristol NHS Foundation Trust Royal College of Obstetricians and Gynaecologists Royal College of Pathologists
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Bristol NHS Foundation Trust
Request that the Royal Colleges consider the report and develop national guidance on urgent LFT reporting reference ranges in pregnancy.
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Bristol NHS Foundation Trust
Raise the issue with the regional obstetric lead for liaison with the national obstetric lead.
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Bristol NHS Foundation Trust
Set up a task and finish group to implement nationally recommended urgent LFT reporting reference ranges safely across the Trust.
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Royal College of Obstetricians and Gynaecologists
Review the Royal College of Pathologists’ response to the report regarding pregnancy-specific thresholds for urgent liver-function-test reporting.
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Royal College of Obstetricians and Gynaecologists
Communicate the review outcome to members and incorporate relevant learning into clinical guidance.
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Royal College of Pathologists
Emphasise the need to agree local critical-result cut-offs with clinicians in the next document revision.
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Lisa Gale · Prevention of Future Deaths report
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Report summary
Lisa Gale developed Acute Fatty Liver of Pregnancy (AFLP) and later died despite hospital treatment and intensive care. The report raises concerns that markedly abnormal liver-function results were not urgently communicated because reporting thresholds did not account for pregnancy-specific conditions, resulting in a delay in diagnosing AFLP and starting appropriate treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of urgent liver function test reporting thresholds to account for pregnancy-specific conditions
Wider context from the report “(1) Blood was taken for liver function tests (LFTs) on admission before her condition was diagnosed;
(2) Lisa’s LFT’s were grossly elevated (normal range in brackets) – ALT 612 (10-50), bilirubin 122 (<21), creatine 168 (45-84);
(3) This was due to a potentially fatal condition – Acute Fatty Liver of Pregnancy – from which she subsequently died;
(3) Despite being grossly elevated, the results once obtained in the laboratory were not phoned through by the laboratory staff to the clinical staff;
(4) This was because the Royal College of Pathologists’ guidelines for urgent reporting only provides for the same with levels above 750 for ALT, 300 for bilirubin and 354 for creatinine – and does not provide for different reporting levels for those taken in pregnant women ;
(5) This is despite pregnancy specific conditions such as AFLP being potentially fatal at much lower levels of abnormal LFTs than those set currently by the Royal College of Pathologists ;
(4) As a result there was a delay in diagnosing her AFLP and starting appropriate treatment.
” Source location Lisa Gale · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate grossly abnormal liver function test results from laboratory staff to clinical staff
Wider context from the report “(1) Blood was taken for liver function tests (LFTs) on admission before her condition was diagnosed;
(2) Lisa’s LFT’s were grossly elevated (normal range in brackets) – ALT 612 (10-50), bilirubin 122 (<21), creatine 168 (45-84);
(3) This was due to a potentially fatal condition – Acute Fatty Liver of Pregnancy – from which she subsequently died;
(3) Despite being grossly elevated, the results once obtained in the laboratory were not phoned through by the laboratory staff to the clinical staff ;
(4) This was because the Royal College of Pathologists’ guidelines for urgent reporting only provides for the same with levels above 750 for ALT, 300 for bilirubin and 354 for creatinine – and does not provide for different reporting levels for those taken in pregnant women;
(5) This is despite pregnancy specific conditions such as AFLP being potentially fatal at much lower levels of abnormal LFTs than those set currently by the Royal College of Pathologists;
(4) As a result there was a delay in diagnosing her AFLP and starting appropriate treatment.
” Source location Lisa Gale · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request that the Royal Colleges consider the report and develop national guidance on urgent LFT reporting reference ranges in pregnancy.
Verbatim wording from the response “To safely implement any recommended changes to reference ranges for LFTs in pregnancy we would ordinarily consider national guidance from the Royal Colleges. We have therefore written to both the Royal College of Pathologists and the Royal College of Obstetricians asking them to” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise the issue with the regional obstetric lead for liaison with the national obstetric lead.
Verbatim wording from the response “At the time of writing, we are awaiting the response from the Royal College of Obstetricians. In the meantime, we have also raised the issue with the regional obstetric lead, who we understand is liaising with the national obstetric lead on this issue.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Set up a task and finish group to implement nationally recommended urgent LFT reporting reference ranges safely across the Trust.
Verbatim wording from the response “Once national guidance has become available regarding a recommended reference range for urgent reporting of LFTs in pregnancy, UHBW will set up a task and finish group, led by Dr Bennett, Dr Willis, and Dr Liebling to implement these across the Trust in a safe and robust manner.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Royal College of Pathologists’ response to the report regarding pregnancy-specific thresholds for urgent liver-function-test reporting.
Verbatim wording from the response “This case highlights the delay in diagnosis of the severity of condition, resulting from the laboratory not using pregnancy specific levels of liver enzymes for reporting of abnormal results. The guidelines from the Royal College of Pathologists ‘The communication of critical and unexpected pathology results’ (2017) recognises that there are variation in results phoned and suggests that this should be set by local need. The RCOG will review the response from the Royal College of Pathologists following this Regulation 28 Report and ensure that this is appropriately communicated with its members and included within relevant clinical guidance.” Source location Response from Royal College of Obstetricians and Gynaecologists
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate the review outcome to members and incorporate relevant learning into clinical guidance.
Verbatim wording from the response “This case highlights the delay in diagnosis of the severity of condition, resulting from the laboratory not using pregnancy specific levels of liver enzymes for reporting of abnormal results. The guidelines from the Royal College of Pathologists ‘The communication of critical and unexpected pathology results’ (2017) recognises that there are variation in results phoned and suggests that this should be set by local need. The RCOG will review the response from the Royal College of Pathologists following this Regulation 28 Report and ensure that this is appropriately communicated with its members and included within relevant clinical guidance.” Source location Response from Royal College of Obstetricians and Gynaecologists
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Emphasise the need to agree local critical-result cut-offs with clinicians in the next document revision.
Verbatim wording from the response “With regards to the RCPath document on The Communication of Critical and Unexpected Pathology results, this document is published as ‘advice to pathologists’ and is offered as a basis on which pathologists can construct their own local guidelines after discussion with relevant stakeholders. It is clearly stated that it is vital that this document is seen as guidance for pathology providers to set their own criteria on how, when, and why particular laboratory results are required to be communicated to clinical professionals in an expedited manner. Whilst recommendations are made within the Appendix on cut offs which can be used, it is recommended that individual cut offs are agreed locally with clinicians, and this could be for a variety of clinical conditions with might include pregnancy.” Source location Response from Royal College of Pathologists
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Changing urgent LFT reference ranges in one Trust alone may create risk through inconsistent guidance and would not address the national issue.
Verbatim wording from the response “We have carefully considered the issue of setting a lower threshold for the urgent reporting reference range for Liver Function Tests (LFTs) in pregnant women. On reflection, we consider that one hospital Trust changing the reference range in isolation will not address the broader issue which has the potential to affect all pregnant women at a national level. UHBW is a tertiary level referral hospital, treating women from across the South-West region. We are concerned that developing guidance in respect of reference ranges for LFTs in pregnant women in UHBW in isolation, could potentially create more risk to patients rather than reduce it, as hospitals within the region, and across the country, would be working to different guidance.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Royal Colleges are asked to consider and develop national guidance on urgent LFT reference ranges in pregnancy.
Verbatim wording from the response “To safely implement any recommended changes to reference ranges for LFTs in pregnancy we would ordinarily consider national guidance from the Royal Colleges. We have therefore written to both the Royal College of Pathologists and the Royal College of Obstetricians asking them to” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local pathology providers and clinicians are responsible for agreeing communication cut-offs; the guidance does not prescribe universal thresholds.
Verbatim wording from the response “With regards to the RCPath document on The Communication of Critical and Unexpected Pathology results, this document is published as ‘advice to pathologists’ and is offered as a basis on which pathologists can construct their own local guidelines after discussion with relevant stakeholders. It is clearly stated that it is vital that this document is seen as guidance for pathology providers to set their own criteria on how, when, and why particular laboratory results are required to be communicated to clinical professionals in an expedited manner. Whilst recommendations are made within the Appendix on cut offs which can be used, it is recommended that individual cut offs are agreed locally with clinicians, and this could be for a variety of clinical conditions with might include pregnancy.” Source location Response from Royal College of Pathologists
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for communicating clinical staff obligations on reviewing electronic results lies with organisations and NHS England or devolved health services.
Verbatim wording from the response “The RCOG however, recognises that there is also an obligation for clinical teams requesting investigations to review the results in a timely manner, depending on the severity of the clinical condition. In the current digital era, laboratory results are available on clinical systems and these should be reviewed by staff caring for the woman. Guidance on the clinician responsibilities is outlined in the GMC Good Clinical Practice 2009, NMC Code of Conduct 2008 and the BMA Acting upon electronic test results (updated in June 2024). Individual trusts/organisations will have specific guidelines applicable to their electronic patient records and it is expected that these, in line with GMC and BMA guidance, would outline the responsibilities of the clinical staff and potential time scales expected.” Source location Response from Royal College of Obstetricians and Gynaecologists
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16 Sep 2024 Samuel Finlay Parkin · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Failure of ultrasound reporting to avoid false reassurance regarding malrotation View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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Samuel Finlay Parkin · 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
Samuel Finlay Parkin died on 16 September 2022 from hypoxic brain injury following a cardiac arrest caused by midgut volvulus. The volvulus resulted from undiagnosed intestinal malrotation, which had been present since birth and was not identified despite repeated symptoms and hospital attendances. The principal concerns included failure to undertake appropriate diagnostic testing, false reassurance from ultrasound reporting, inadequate safety-netting advice, and communication and learning issues between clinical teams.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of ultrasound reporting to avoid false reassurance regarding malrotation
Wider context from the report “2. In the course of the evidence it became clear that the inclusion of a comment in the ultrasound report that the SMA/SMV axis was normal gave false reassurance regarding malrotation . The consultant paediatric radiologist was clear that she was not looking for malrotation on the USS (as it was not listed as a potential diagnosis on the ultrasound request), that USS cannot be used to exclude malrotation and that noting that the axis is normal was simply a comment on the anatomy seen and was not the radiologist providing information relating to whether or not malrotation was present. It is recorded in the notes of the M&M meeting which took place following Sam’s death and in the evidence that I heard, that although clinicians understood that USS is not the diagnostic test for malrotation and that malrotation will not be seen on an USS in circa 25% of cases, the recording of the axis being normal gave a false reassurance . St George’s has changed their practice of reporting of USS to avoid potential confusion in the future. I consider action is required to ensure proper understanding of the limitations of USS in looking for malrotation, in particular in older children, and to avoid any similar confusion regarding the reporting of USS both in St George’s and across the NHS.
” Source location Samuel Finlay Parkin · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Formalise the paediatric abdominal reporting standard in local radiology protocols and audit reports for quality assurance.
Verbatim wording from the response “The limitations of the SMA/SMV axis alone as a marker for malrotation, in particular in older children, are part of the shared learning being disseminated locally. This is now a regular topic for departmental training for paediatric radiology registrar level doctors. The change in the paediatric abdominal reporting standard at St George’s is formalised in local radiology protocols, with quality assurance through active audit of reports. This will be part of a presentation during a dedicated malrotation session, organised and led by the St George’s team, at the British Society of Paediatric Radiology meeting in November 2024.” Source location Response from St George's Epsom and St Helier University Hospitals
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24 Jul 2024 Regan Edwin James SMITH · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Failure of patient handover processes to ensure significant clinical findings are available to receiving clinicians View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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Regan Edwin James SMITH · Prevention of Future Deaths report
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Report summary
Regan Smith died at Kings College Hospital on 31 January 2023 after previously undiagnosed diabetes led to severe metabolic acidosis, multiorgan failure and acute liver failure. An abnormal blood glucose reading obtained by ambulance staff was not effectively handed over or recorded at hospital, resulting in his discharge without further glucose testing or treatment. The report identifies concerns about incompatible information systems, reliance on verbal handover during a period of high acuity, and the absence of national standards for emergency department handovers and confirmation of basic observations.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of patient handover processes to ensure significant clinical findings are available to receiving clinicians
Wider context from the report “The information to save Regan’s life (his abnormal blood glucose reading) was in the possession of the NHS at a time when lifesaving treatment could have been given to him on the 25th January 2023.
Regan’s death occurred as the result of an identifiable single point of failure (the ineffective handover process ), as this led to a significant and known clinical finding being unavailable to his treating clinicians .
Evidence heard that the handover system in Regan’s case was reliant on both ambulance and Accident and Emergency personnel making and receiving a verbal handover . The IT systems used by the Ambulance and Hospital Trusts are not directly compatible, and therefore clinical information (such as blood glucose level test results) are not immediately available to hospital personnel in every case.
It was heard that Regan’s verbal only handover occurred during a period of very high acuity.
On the 25th January 2023 the unit was exceptionally busy, the staff there had a high number of other sick children to care for, there was no cubicle space available, and the staff had not been able to take any of their scheduled breaks. When Regan did see a clinician, it was in the corridor.
It was heard in evidence that there was no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, in relation to the conduct of patient handovers at Accident and Emergency Units.
In addition, there is no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, to ensure basic observations are confirmed as being received by the receiving Accident and Emergency personnel.
” Source location Regan Edwin James SMITH · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop IT support linking ambulance and emergency department systems to improve electronic clinical information sharing.
Verbatim wording from the response “The rapid exchange of clinical information verbally remains an integral part of communication. However, work is ongoing with NHSE to provide IT support that can deliver improved sharing of electronic information across systems. Linking the ambulance computer aided despatch system and electronic patient record collected by ambulance services with emergency departments data will provide better information about the patient journey.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implementation and oversight of clinical handover protocols across England are the responsibility of local organisations.
Verbatim wording from the response “Regarding the formal clinical handover of patients, there are a number of protocols that should be followed. This includes standards set out by the General Medical Council on how patient information should be shared, and the NHS standard contract which sets out targets on handover delays. The responsibility for the implementation and oversight of protocols across England is at a local level. I understand that ESNEFT submitted evidence during the inquest which set out actions being taken locally to improve processes which you have considered and were content with. EEAST advise that in the East of England, all hospital A&Es have information systems to provide records of patients arriving by ambulance and that they are ensuring that ambulance patient care records are available as part of the assessment of patients who arrive at A&E by ambulance.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local process improvements and ambulance information systems provide an adequate response to clinical handover and patient-record concerns.
Verbatim wording from the response “Regarding the formal clinical handover of patients, there are a number of protocols that should be followed. This includes standards set out by the General Medical Council on how patient information should be shared, and the NHS standard contract which sets out targets on handover delays. The responsibility for the implementation and oversight of protocols across England is at a local level. I understand that ESNEFT submitted evidence during the inquest which set out actions being taken locally to improve processes which you have considered and were content with. EEAST advise that in the East of England, all hospital A&Es have information systems to provide records of patients arriving by ambulance and that they are ensuring that ambulance patient care records are available as part of the assessment of patients who arrive at A&E by ambulance.” Source location Response from DHSC
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17 Jul 2024 David Nicholas ALMOND · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to recognise the need for follow-up medical review after a negative x-ray View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
East Cheshire NHS Trust NHS England
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David Nicholas ALMOND · 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
David Nicholas Almond was diagnosed with thrombophilia and deep vein thrombosis but was not placed on lifelong anticoagulation. After developing breathlessness that was investigated with an X-ray, he collapsed and was found to have a massive pulmonary embolism, dying in hospital on 5 January 2024. The principal concerns were incomplete access to and recognition of relevant GP records, and failure to arrange appropriate follow-up after the negative X-ray.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise the need for follow-up medical review after a negative x-ray
Wider context from the report “3. The inquest heard evidence that in September 2023 when he went to his GP practice he did not see a doctor. It was not recognised by the practitioner who saw him that there may need to be a follow-up appointment or a recommendation that he return to see a doctor should the x ray be negative given his history and presentation.
” Source location David Nicholas ALMOND · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GP surgery is responsible for responding to concerns about the care it provided and appointment access arrangements.
Verbatim wording from the response “My response to your concerns focuses on those areas of concern that fall under the remit of national NHS England policy or programme work. Your concerns relating to East Cheshire NHS Trust’s recording sharing and access arrangements, along with your concerns about the care provided at the GP surgery, are more appropriately answered by the two organisations. The Standard General Medical Services (‘GMS’) Contract also sets out the requirements on GP Practices. Practices should provide enough appointments to meet the reasonable need of their patients, and provision of appointments and advice or care should consider their patients’ preferences where appropriate.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GP practice contact concerned care outside the Trust’s remit because it was not delivered by East Cheshire NHS Trust.
Verbatim wording from the response “As this concern relates to Mr Almond’s clinical contact with his GP practice and not to care delivered by East Cheshire NHS Trust, we have sought the input of the gtd healthcare for the GP practice to provide the response that follows:” Source location Response from East Cheshire Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GP practice’s provider, gtd healthcare, is responsible for responding to concerns about that primary care contact.
Verbatim wording from the response “As this concern relates to Mr Almond’s clinical contact with his GP practice and not to care delivered by East Cheshire NHS Trust, we have sought the input of the gtd healthcare for the GP practice to provide the response that follows:” Source location Response from East Cheshire Trust
Open published response
19 Jun 2024 Thomas Gibson · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Lack of required senior review when diagnostic results are incongruous or unexpected in context View source Lack of minimum standards for obtaining clinical context when reviewing isolated test or investigation results View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Thomas Gibson · 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
Mr Gibson was found dead at home on 7 June 2023, with the death attributed to sudden cardiac death due to idiopathic myocardial fibrosis. Eleven days earlier, two ECGs were not recognised as showing complete heart block, and he was discharged from hospital. Concerns included inadequate communication and contextual review of test results, lack of senior review when findings were unexpected, insufficient auditing of ECG interpretation and discharge summaries, and the absence of authoritative national guidance on ECG use and interpretation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of required senior review when diagnostic results are incongruous or unexpected in context
Wider context from the report “4. I am also concerned that there does not currently appear to be any particular requirement in place for a senior review of the patient to take place in circumstances where diagnostic tests undertaken yield results which appear incongruous / unexpected in the context of their presentation .
” Source location Thomas Gibson · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of minimum standards for obtaining clinical context when reviewing isolated test or investigation results
Wider context from the report “3. Connected with the above, I am concerned that the court heard evidence to the effect there is no specific guidance as to expected minimum standards as to obtaining appropriate context / information for clinicians (whether from the HIVE system or otherwise) when asked to review a single test or investigation result in isolation .
” Source location Thomas Gibson · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver regular ECG interpretation teaching and promote second opinions from appropriately qualified clinicians or cardiologists.
Verbatim wording from the response “ECG training is delivered regularly as part of the Wythenshawe medical teaching programme. The training also encourages junior members of the team and other Health Care Professionals (HCPs) to have a low threshold to seek a second opinion either from a Consultant/Specialist Trainee (who are signed off as competent to interpret ECGs independently) or cardiologist.” Source location Responses from NICE and MFT
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand simulation and Human Factors training through a rolling programme for junior doctors across MFT sites.
Verbatim wording from the response “The concept of “human factors” in healthcare is described as “enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings”.² We are therefore expanding our simulation and Human Factors training. This HF training will form part of regular teaching programmes for medical and surgical junior doctors and the content and syllabus will be discussed with the HFA. The aim is to have a rolling 12-month programme established by 31 December 2024. This programme will look at how to provide training across MFT sites.” Source location Responses from NICE and MFT
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Registrar review is considered an appropriately senior arrangement, so consultant oversight of every ECG is not considered reasonable.
Verbatim wording from the response “4. Whilst no Consultant reviewed the ECG prior to Mr Gibson being discharged, the Registrars did review this. A Registrar is an appropriately senior clinician to discharge a patient; it is not anticipated or reasonable for a Consultant to oversee all ECG interpretation 24 hours a day, as the opportunity cost of this would adversely impact other activity that necessitates Consultant input.” Source location Responses from NICE and MFT
Open published response
Concerns raised 3
Lack of an electronic laboratory-to-emergency-department alert system for abnormal results View source Failure to act on abnormal blood results View source Failure to document abnormal blood results in emergency department records View source
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AI-generated summary
Eric Thompson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Eric Thompson presented with confusion and poor mobility and was found to have high potassium levels. The results were not initially documented or escalated, he did not receive treatment for hyperkalaemia, and he subsequently suffered cardiac arrest and died; the report identified concerns about reliance on person-to-person communication without an electronic alert system for abnormal laboratory results.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of an electronic laboratory-to-emergency-department alert system for abnormal results
Wider context from the report “The abnormal blood results were telephoned through to the emergency department as required by the current system within an hour of the blood being taken to highlight the abnormal results. The results were available on the system; but they were not initially documented by the emergency department following the telephone call. They were not actioned, nor were they noted until many hours later until a clinician actively considered the electronic emergency department medical records for Mr Thompson.
There is no electronic or IT method or system by which the laboratory can send the results to the emergency department quickly and efficiently with an alert to indicate abnormal results. Instead, the system relies on person-to-person discussions and for this to then be escalated, as necessary.
” Source location Eric Thompson · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to act on abnormal blood results
Wider context from the report “The abnormal blood results were telephoned through to the emergency department as required by the current system within an hour of the blood being taken to highlight the abnormal results. The results were available on the system; but they were not initially documented by the emergency department following the telephone call. They were not actioned , nor were they noted until many hours later until a clinician actively considered the electronic emergency department medical records for Mr Thompson.
There is no electronic or IT method or system by which the laboratory can send the results to the emergency department quickly and efficiently with an alert to indicate abnormal results. Instead, the system relies on person-to-person discussions and for this to then be escalated, as necessary.
” Source location Eric Thompson · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to document abnormal blood results in emergency department records
Wider context from the report “The abnormal blood results were telephoned through to the emergency department as required by the current system within an hour of the blood being taken to highlight the abnormal results. The results were available on the system; but they were not initially documented by the emergency department following the telephone call . They were not actioned, nor were they noted until many hours later until a clinician actively considered the electronic emergency department medical records for Mr Thompson.
There is no electronic or IT method or system by which the laboratory can send the results to the emergency department quickly and efficiently with an alert to indicate abnormal results. Instead, the system relies on person-to-person discussions and for this to then be escalated, as necessary.
” Source location Eric Thompson · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review, revise and update telephone-alert procedures across all three emergency departments, establishing a clear mechanism for receiving and acting on abnormal laboratory results.
Verbatim wording from the response “To that end, our three hospital Medical Directors will work with all of our three ED teams to review, revise and update the processes in place to ensure there is a clear mechanism for telephone alerts to be received and acted upon. That work will include ensuring the learning from this case is cascaded, that procedures are considered and updated, and importantly that staff are aware of those procedures.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cascade learning from the case across all three emergency departments and ensure staff are aware of the updated telephone-alert procedures.
Verbatim wording from the response “To that end, our three hospital Medical Directors will work with all of our three ED teams to review, revise and update the processes in place to ensure there is a clear mechanism for telephone alerts to be received and acted upon. That work will include ensuring the learning from this case is cascaded, that procedures are considered and updated, and importantly that staff are aware of those procedures.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Telephone alerts remain an adequate safety arrangement and are unlikely to be replaced by a future electronic alert system.
Verbatim wording from the response “In specific relation to the issue of abnormal results being communicated to the emergency department (ED) quickly, our Medical Directors have discussed this with senior clinicians and they have identified the telephone alert process is standard in most EDs. This method of alert is more likely to bring the abnormal result to the attention of the department than an IT related alert, due to the dynamic nature of the ED and the fact that most clinicians will be working agile and with patients rather than by a computer. Therefore, the arrangement of phone alerts would still have a valuable role in safety and is not likely to be replaced by any future electronic system (although we acknowledge such systems may provide improved access to information).” Source location Response from Betsi Cadwaladr University Health Board
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5 Jun 2024 Bernard Compton · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to ensure urgent blood results are acted upon immediately View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Bernard Compton · 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
Bernard Compton developed symptoms of a myocardial infarction, but delays in ambulance response, ECG interpretation, triage, blood-result review and clinical assessment meant that the optimum window for intervention had passed. He later suffered a left ventricular rupture and died on 19 October 2023. The concerns included inadequate oversight of patients and urgent results, unclear systems for repeating and acting on tests, and demand-related delays in ambulance and emergency care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure urgent blood results are acted upon immediately
Wider context from the report “It was unclear what system was in place to effectively ensure urgent blood results were acted upon immediately . The inquest was told the lab would telephone through on some occasions. It was unclear what the protocol was and who had oversight of it .
” Source location Bernard Compton · Prevention of Future Deaths report
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29 May 2024 George Barry Broadhurst · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Delays in specialist reporting of X rays View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
NHS England
Expand Clinical Radiology specialty training places to increase the trained reporting workforce.
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NHS England
Continue international recruitment of radiologists to support diagnostic capacity, with demand planning underway for further recruitment.
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NHS England
Deliver the Long Term Workforce Plan, including expanded domestic education, training and recruitment and workforce retention measures.
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AI-generated summary
George Barry Broadhurst · 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
George Barry Broadhurst sustained a vertebral fracture in an accidental fall, which was not identified on an initial x-ray review. He later deteriorated with a collapsed lung, pulmonary embolism and an infected fractured vertebra, and died in hospital on 10 October 2023. The principal concerns were delays in radiology reporting and review, and insufficient recognition and escalation of concerning pain and deterioration in the community.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in specialist reporting of X rays
Wider context from the report “1. The inquest heard evidence that the delay in reporting of X rays by radiologists is not unique to Tameside but is a national picture caused by a shortage of radiologists and trained reporting radiographers . The impact of the shortage is that ED doctors are interpreting x rays in highly pressured situations without specialist input and with a consequential risk of missing more subtle fractures. This means that patients are discharged with fractures rather than appropriate treatment or conversely are given unnecessary treatment that then has to be reversed once a specialist review takes place.
” Source location George Barry Broadhurst · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand Clinical Radiology specialty training places to increase the trained reporting workforce.
Verbatim wording from the response “Following additional investment through spending review settlements in 2021/22 and 2022/23, the NHS has observed a significant and sustained expansion in recruitment to specialty training places. Clinical Radiology recruitment increased from an average of 234 trainees per year (between 2016 and 2020) to an average of 328 (between 2021 and 2022), meaning an expansion of around 100 specialty trainee places per year.” Source location Response from NHSE
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue international recruitment of radiologists to support diagnostic capacity, with demand planning underway for further recruitment.
Verbatim wording from the response “A programme of international recruitment also ran in 2023/24 to enable Community Diagnostic Centres (CDCs) to deliver diagnostics and achieve the benefits in access, recovery and transformation of care. During 2023/24, 21 Radiologists were appointed through the programme. Further international recruitment is planned for 2024/25, with demand planning currently underway.” Source location Response from NHSE
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the Long Term Workforce Plan, including expanded domestic education, training and recruitment and workforce retention measures.
Verbatim wording from the response “NHS England is also working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of” Source location Response from NHSE
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Trusts are responsible for ensuring safe staffing levels in hospitals’ current day-to-day operations.
Verbatim wording from the response “people, with the right skills and support in place, to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years. These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however NHS Trusts have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals.” Source location Response from NHSE
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local A&E procedures require follow-up of X-ray reports because general X-rays may not receive 24/7 imaging-service reporting.
Verbatim wording from the response “Accident & Emergency (A&E) departments are required to have local procedures in place to ensure that they follow up X-ray reports, based on the formal report being finalised, as pathologies can be missed via A&E routes and imaging services do not support/deliver 24/7 reporting of general X-rays.” Source location Response from NHSE
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.