3 Aug 2022 Mrs Rita Flynn · Prevention of Future Deaths report Black Country
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Concerns raised 1
Failure to await blood test results before discharge View source
Linked response
the Royal Wolverhampton NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
the Royal Wolverhampton NHS Trust
Incorporate proactive blood-result review into postgraduate induction training and disseminate the requirement to postgraduate staff.
View source
the Royal Wolverhampton NHS Trust
Use the ED clerking form’s investigations-and-results section to document blood-result review before discharge.
View source
the Royal Wolverhampton NHS Trust
Allocate consultant work-plan time to review blood results in the ICE system within 24 hours.
View source
the Royal Wolverhampton NHS Trust
Review and include the discharge blood-result process in ED policy and guidance.
View source See 1 more action
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AI-generated summary
Mrs Rita Flynn · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Rita Flynn became ill with flu-like symptoms and was assessed by her GP and New Cross Hospital. Her condition deteriorated, with shortness of breath and haemoptysis, and she was discharged home before blood-test results indicating infection were available; she died at home on 4 February 2022. The inquest found that she died after complications arising from a lung abscess, and the concern identified was that it would have been best practice to wait for the blood-test results before discharge.
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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 await blood test results before discharge
Wider context from the report “1. Evidence emerged during the inquest that there were clear indicators of an infection and before being discharged home by the hospital, it would have been best practice to wait for the blood tests results .
” Source location Mrs Rita Flynn · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate proactive blood-result review into postgraduate induction training and disseminate the requirement to postgraduate staff.
Verbatim wording from the response “There has been an agreed plan within ED to incorporate within the training portfolio of postgraduate doctors, the importance of an initiative-taking and proactive review of blood results prior to discharge of patients. Such training will be delivered at induction level.” Source location Response from The Royal Wolverhampton
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the ED clerking form’s investigations-and-results section to document blood-result review before discharge.
Verbatim wording from the response “An ED clerking document is completed by reviewing staff including Doctors, within the Clerking form a section for investigations and results has been incorporated so that such results and investigations are documented. All Doctors/Clinicians will complete the investigations review section. This will be assurance and used as a checklist criteria to show evidence that results have been reviewed, as well as results being filed at the time they have been seen prior to the discharge of patients.” Source location Response from The Royal Wolverhampton
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allocate consultant work-plan time to review blood results in the ICE system within 24 hours.
Verbatim wording from the response “Consultants on duty will be allocated time within their work plan to review blood results in the Clinical Webb Portal - ICE system (system which records all results), to review blood results in a timely manner (within 24 hours).” Source location Response from The Royal Wolverhampton
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and include the discharge blood-result process in ED policy and guidance.
Verbatim wording from the response “1. To consider reviewing your policy and guidance on discharge of patients before blood test results are known particularly where there is evidence of infection showed.” Source location Response from The Royal Wolverhampton
Open published response
17 Jul 2022 Kathleen Stewart · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to act on abnormal clinical imaging reports and provide indicated follow-up View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Tameside and Glossop Integrated Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Tameside and Glossop Integrated Care NHS Foundation Trust
Introduce and test an electronic RAG-priority radiology reporting and alerting system for Emergency Department findings.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Implement a reporting and escalation SOP covering responsibilities, documentation, monitoring, oversight and escalation of unread or unacknowledged findings.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Prioritise and monitor daily Emergency Department Consultant review of radiology reports, with administrative processing of required actions.
View source
Tameside and Glossop Integrated Care NHS Foundation Trust
Require Consultant review on the day for specified X-rays received by the Emergency Department before 22:00.
View source See 1 more action
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AI-generated summary
Kathleen Stewart · 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
Kathleen Stewart fell at her care home and was taken to hospital after reporting groin pain. Her pelvic X-ray was later reported as showing a minimally displaced fracture, but the report was not acted upon; she was discharged without the indicated follow-up and subsequently deteriorated and died. The concerns included the failure to act on the abnormal imaging report and the lack of a specific investigation into the incident and related systems.
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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 clinical imaging reports and provide indicated follow-up
Wider context from the report “1. The court heard evidence that, whilst the Middle Grade doctor who treated Mrs Stewart in the Emergency Department did not identify any bony injury, a Radiographer who formally reported on the pelvic X-Ray the following day identified a minimally displaced fracture of the right superior pubic ramus;
It is a matter of concern that this X-Ray report was not acted upon , and as such Mrs Stewart did not receive the indicated follow up of analgesia and referral for physiotherapy ;
2. It is a further matter of concern that the Trust does not appear to have undertaken any specific investigation as to why this was the case. As such, the Trust has not taken the opportunity to:-
a) Identify what went wrong in Mrs Stewart’s case and ascertain what learning can be derived from the incident;
b) Ascertain whether this was an isolated incident or whether there was (or is) a broader problem in relation to acting on abnormal reports of clinical imaging (and if so, the nature and extent of any such problem); or
c) Consider the fitness or purpose of the system in place within the Emergency Department for acting on abnormal reports of clinical imaging.
” Source location Kathleen Stewart · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce and test an electronic RAG-priority radiology reporting and alerting system for Emergency Department findings.
Verbatim wording from the response “Whilst the Trust has current safety net procedures in place, we are working to introduce a system whereby a Radiologist or Reporting Radiographer will be able to immediately assign a level of priority to each report in the Radiology reporting system, CRIS. This will be completed using a using a Red-Amber-Green (RAG) rating.” Source location Response from NHS Tameside and Glossop Integrated Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a reporting and escalation SOP covering responsibilities, documentation, monitoring, oversight and escalation of unread or unacknowledged findings.
Verbatim wording from the response “A Standard Operating Procedure (SOP) has been developed to support the roll out of this new electronic capability, which provides an explanation of the reporting and escalation process and outlines the clinical responsibilities of both Radiology and Emergency Department colleagues. The SOP includes monitoring and oversight arrangements to ensure compliance with the process. The SOP also provides clear guidance on the need to record action taken in relation to any abnormal results identified after the patient has left the Department, this will be recorded in the patient’s electronic notes. The automated alerting system will also have the capability to escalate any un-read or un-acknowledged radiology findings to operational and clinical leads for action.” Source location Response from NHS Tameside and Glossop Integrated Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise and monitor daily Emergency Department Consultant review of radiology reports, with administrative processing of required actions.
Verbatim wording from the response “In the interim, to mitigate risk Emergency Department Consultant reviews of all radiology reports received within the Department is being prioritised and is being monitored on a daily basis by the Urgent Care Clinical Director and Associate Divisional Director, overseen by the Medicine and Urgent Care Divisional Quality and Safety Board. For those radiology reports where an action is required the Emergency Department Consultants work with the Urgent Care” Source location Response from NHS Tameside and Glossop Integrated Care
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require Consultant review on the day for specified X-rays received by the Emergency Department before 22:00.
Verbatim wording from the response “The audit will be used to inform future teaching sessions for junior doctors; providing additional education in respect of pubic rami, lumbar spine and thoracic spine X-Rays. These X-Rays will also be reviewed by a Consultant on the day of performance where received by the Emergency Department prior to 22:00 hours. This is intended to reduce the occasions on which injuries are not identified by doctors within the Emergency Department.” Source location Response from NHS Tameside and Glossop Integrated Care
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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 An audit found that the small number of fractures missed by Emergency Department clinicians were acted upon appropriately when radiology reports were received.
Verbatim wording from the response “The investigation was informed by an audit of radiology findings, using a large random sample from June 2022. In respect of Emergency Department clinicians identifying fractures, the audit found that the Trust scored favourably when compared to the National average (3.1%, compared to 3.7% Nationally). The audit also identified that the small number of fractures not identified by Emergency Department clinicians were all acted upon appropriately when the report was received from a Radiologist or Reporting Radiographer.” Source location Response from NHS Tameside and Glossop Integrated Care
Open published response
14 Jul 2022 Gordon Bernard Hendley · Prevention of Future Deaths report Cumbria
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Concerns raised 1
Failure to record recognition of the significance of critical blood-test results View source
This report raised 9 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
Gordon Bernard Hendley · 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
Gordon Bernard Hendley, who had lymphoma and recent lung infection and pulmonary embolism, developed a severe rash most likely caused by Stevens-Johnson Syndrome and died in hospital on 23 January 2022 after maximal treatment. The report identified concerns about delays in medical assessment and treatment, failure to escalate significant blood-test results, lack of specialist dermatology input and prognostic scoring, and the robustness of systems for monitoring and supporting severely ill patients.
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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 record recognition of the significance of critical blood-test results
Wider context from the report “3) Gordon had a CT scan, he was referred to medicine but not seen by a medical consultant until 4.30 pm, he was to be admitted to a ward (this happened at 6.30pm) but there is no record in the notes of the significance of the earlier blood test being appreciated .
” Source location Gordon Bernard Hendley · Prevention of Future Deaths report
Open source report
7 Jul 2022 Seema Pravin HARIBHAI · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Delay in responding to markedly abnormal blood test results View source
This report raised 11 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
Seema Pravin HARIBHAI · 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
Seema Haribhai, who had increasingly disabling psoriatic arthritis, took herbal remedies prescribed by an Ayurvedic practitioner and developed liver failure, dying some weeks later. The investigation determined that she died as a consequence of the administration of Ayurvedic medicines intended to treat psoriatic arthritis. Concerns included the practitioner’s failure to recognise the possible harm from the medicines or advise their immediate cessation, the lack of regulation and evidence of quality control, and shortcomings in the GP’s assessment and response to her symptoms and abnormal blood test.
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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 Delay in responding to markedly abnormal blood test results
Wider context from the report “The GP consultation was on 5 November, the blood test was conducted on 9 November, the results came back to the surgery on 10 and 11 November, and an appointment was booked for 15 November . Meanwhile, same day admission to hospital was arranged on 15 November solely because a nurse had noted the blood test result at a routine rheumatology appointment .
The blood test result was so abnormal that, even without examination, the consult rheumatologist saw no option but immediate admission .
” Source location Seema Pravin HARIBHAI · Prevention of Future Deaths report
Open source report
3 Apr 2022 Edward Arthur AKROYD · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 2
Failure to obtain available laboratory results for treatment planning View source Failure to communicate laboratory results to treating clinicians 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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Edward Arthur AKROYD · 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
Edward Arthur Akroyd was delivered by forceps on 13 January 2018 at Calderdale Royal Hospital after concerns arose during his mother’s labour, including pre-eclampsia and abnormal CTG tracing. He was transferred to Leeds General Infirmary for intensive treatment and died there on 17 January 2018. The principal concerns included inadequate monitoring and treatment of his mother’s elevated blood pressure, incomplete handover and medical records, failure to communicate laboratory results, and delayed recognition and interpretation of non-reassuring CTG findings.
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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 obtain available laboratory results for treatment planning
Wider context from the report “9. The same registrar stated in evidence that he was aware that samples had been taken at Huddersfield Birthing Centre but didn’t think there was a need to obtain the results to assist in determining an appropriate treatment plan. I am concerned that if similar circumstances were to reoccur it may pose a risk to the wellbeing of the expectant mother and their unborn child.
” Source location Edward Arthur AKROYD · Prevention of Future Deaths report
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 to communicate laboratory results to treating clinicians
Wider context from the report “3. After a diagnosis of pre-eclampsia was made at Huddersfield birthing centre and Prior to transfer, various samples were obtained and sent for laboratory analysis, some of the results were received at Huddersfield Birthing Centre and phoned through to the labour ward at Calderdale Royal Hospital. From the evidence presented, the results were not passed to Mrs Akroyds attendant midwife or treating registrar . The subsequent internal review did not appear to investigate and determine the reason why this did not occur.
I am concerned that if this were to reoccur, important information may not be provided which could pose a risk to the wellbeing of an expectant mother and their unborn child
” Source location Edward Arthur AKROYD · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement automatic transfer of laboratory results into the primary patient record and display them on the Trust-wide system home screen.
Verbatim wording from the response “The computer system for reporting results has changed since 2018. As soon as results are put onto the laboratory computer system those results are pulled through to the primary patient record and can then be seen on the “home” screen of the Trust wide system. Any doctor or midwife can therefore check on the blood test results, including remote access, for example, on an on call consultant accessing the system from home. This means there is no need for the results to be phoned through or passed on verbally.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
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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 internal investigation could not pursue why laboratory results were not passed on because the recipient could not be identified.
Verbatim wording from the response “It should be noted that there was no diagnosis of pre-eclampsia at the Huddersfield Birthing Centre. High blood pressure was recognised. Nevertheless, the results of the blood tests should have been accurately passed on. It was not felt possible to pursue the matter in the” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
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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 Automatic laboratory-result availability in the primary record is considered sufficient, removing the need for results to be phoned through or verbally passed on.
Verbatim wording from the response “The computer system for reporting results has changed since 2018. As soon as results are put onto the laboratory computer system those results are pulled through to the primary patient record and can then be seen on the “home” screen of the Trust wide system. Any doctor or midwife can therefore check on the blood test results, including remote access, for example, on an on call consultant accessing the system from home. This means there is no need for the results to be phoned through or passed on verbally.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
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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 Trust considers the doctor’s changed practice, including proactive information review and communication training, sufficient to address handover and record-review concerns.
Verbatim wording from the response “Please see the response to concern 5 above.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
Open published response
13 Jan 2022 Darran Busby · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2
Failure of the result-filing function to prevent multiple-click filing of subsequent results without clinician review View source Lack of a failsafe for abnormal radiology results to prompt clinician review View source
Linked responses
EMIS Group North Cumbria Integrated Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
North Cumbria Integrated Care NHS Foundation Trust
Test a workable EMIS solution and continue collaborating with EMIS on system fixes, user communication and escalation of identified risks.
View source
North Cumbria Integrated Care NHS Foundation Trust
Return the Cockermouth Hospital community ward to the ICE Order Comms system after assessing the affected functionality.
View source
North Cumbria Integrated Care NHS Foundation Trust
Increase Neurology team vigilance when reviewing results and stop using “file no comment” in favour of “File and Comment” to require clinician review.
View source
North Cumbria Integrated Care NHS Foundation Trust
Implement a separate Rad Alert system that emails referrers about significant radiology findings and escalates unacknowledged alerts to alternative clinicians.
View source
North Cumbria Integrated Care NHS Foundation Trust
Notify Primary Care colleagues using EMIS about the risk and required precautions through the CCG Chief Clinical Information Officer.
View source
EMIS Group
Continue collaborating with NHS Digital on modern messaging standards to improve normal and abnormal result flagging.
View source
EMIS Group
Review results-filing training materials to emphasise detailed review of radiology and other results that may lack abnormal flags.
View source See 4 more actions
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AI-generated summary
Darran Busby · 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
Darran Busby was at home with his family on 14 August 2021 and ended his life. Before his death, he had undergone an MRI scan after complaining of headaches, but the result was never reviewed by a clinician. The report raised concerns that weaknesses in the electronic systems could allow radiology results requiring urgent follow-up to be filed without clinical review, potentially creating a risk of future deaths.
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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 the result-filing function to prevent multiple-click filing of subsequent results without clinician review
Wider context from the report “After it became apparent that the result of Mr Busby's MRI scan had not been reviewed by a clinician, a consultant employed by North Cumbria Integrated Care NHS Foundation Trust ('the Trust') undertook an investigation. He noted that the Trust use EMIS as an electronic patient record. He explained that the Trust used a separate system called ICE to gather the results of tests or scans. ICE is capable of linking to EMIS to input results into the EMIS system. Once a test result has been linked to a patient in EMIS the result enters the EMIS record as a provisional result pending review, and is placed on a work list. The consultant or a deputy then reviews the result, files it with or without comment and records any actions taken. EMIS provides two options: 'file no comment' and 'file and comment'. Results of blood tests which are undertaken to monitor treatment and which are normal may be filed without comment. If there is an abnormality flagged, however, EMIS will default to the file with comment dialogue box even if file no comment is selected. This acts as a safeguard against missing a significant finding. Unfortunately, there is no flag attached in the ICE system for abnormal radiology results, and so no failsafe exists for defaulting to a 'file and comment' if a significant positive or negative finding is reported.
In the course of investigating what occurred in relation to Mr Busby's MRI scan, it was determined that clicking more than once on the 'file no comment' button will result in the displayed result being filed, but will also result in filing of the next in the list if that result has no flag indicating the result is abnormal. Thus if a radiology result lies below a normal blood result and a clinician inadvertently double clicks to file the first result, the radiology result is also filed without comment and without the result being displayed. Furthermore, multiple clicks up to 6 (and perhaps even beyond) will lead to multiple filings. In the result it is possible that a clinician inadvertently clicking 'file no comment' more than once on one result would cause results which require urgent follow up being filed without a clinician being involved.
I am concerned that this might lead to lost opportunities to treat patients whose scans reveal, for instance, early malignancies. It might also mean that scans which reveal the need for urgent action will be overlooked. I am therefore concerned that future deaths will occur.
I was impressed by the candour of the report provided to me and the efforts that the Trust have already taken to resolve this issue. However I noted that the evidence I received was that "In order to fix this issue it is likely it will require action by the publishers of EMIS to prevent accidental filing of results. To attempt to mitigate this issue whilst a permanent fix is sought I have worked with colleagues from Pathology and Radiology to attempt to have all radiology results (where the greatest risk lies) flagged within the ICE system as abnormal, so that any attempt to file the result prompts via the file and comment dialogue box. Unfortunately at the time of writing this letter the flag, which is triggered in ICE for any radiology report originating within Cumbria Neuroscience, does not carry through to EMIS
and we continue to seek a local solution to mitigate this newly identified risk."
In the circumstances I have concluded that it is necessary for action to be taken to prevent future deaths.
” Source location Darran Busby · Prevention of Future Deaths report
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 Lack of a failsafe for abnormal radiology results to prompt clinician review
Wider context from the report “After it became apparent that the result of Mr Busby's MRI scan had not been reviewed by a clinician, a consultant employed by North Cumbria Integrated Care NHS Foundation Trust ('the Trust') undertook an investigation. He noted that the Trust use EMIS as an electronic patient record. He explained that the Trust used a separate system called ICE to gather the results of tests or scans. ICE is capable of linking to EMIS to input results into the EMIS system. Once a test result has been linked to a patient in EMIS the result enters the EMIS record as a provisional result pending review, and is placed on a work list. The consultant or a deputy then reviews the result, files it with or without comment and records any actions taken. EMIS provides two options: 'file no comment' and 'file and comment'. Results of blood tests which are undertaken to monitor treatment and which are normal may be filed without comment. If there is an abnormality flagged, however, EMIS will default to the file with comment dialogue box even if file no comment is selected. This acts as a safeguard against missing a significant finding. Unfortunately, there is no flag attached in the ICE system for abnormal radiology results, and so no failsafe exists for defaulting to a 'file and comment' if a significant positive or negative finding is reported.
In the course of investigating what occurred in relation to Mr Busby's MRI scan, it was determined that clicking more than once on the 'file no comment' button will result in the displayed result being filed, but will also result in filing of the next in the list if that result has no flag indicating the result is abnormal. Thus if a radiology result lies below a normal blood result and a clinician inadvertently double clicks to file the first result, the radiology result is also filed without comment and without the result being displayed. Furthermore, multiple clicks up to 6 (and perhaps even beyond) will lead to multiple filings. In the result it is possible that a clinician inadvertently clicking 'file no comment' more than once on one result would cause results which require urgent follow up being filed without a clinician being involved.
I am concerned that this might lead to lost opportunities to treat patients whose scans reveal, for instance, early malignancies. It might also mean that scans which reveal the need for urgent action will be overlooked. I am therefore concerned that future deaths will occur.
I was impressed by the candour of the report provided to me and the efforts that the Trust have already taken to resolve this issue. However I noted that the evidence I received was that "In order to fix this issue it is likely it will require action by the publishers of EMIS to prevent accidental filing of results. To attempt to mitigate this issue whilst a permanent fix is sought I have worked with colleagues from Pathology and Radiology to attempt to have all radiology results (where the greatest risk lies) flagged within the ICE system as abnormal, so that any attempt to file the result prompts via the file and comment dialogue box. Unfortunately at the time of writing this letter the flag, which is triggered in ICE for any radiology report originating within Cumbria Neuroscience, does not carry through to EMIS
and we continue to seek a local solution to mitigate this newly identified risk."
In the circumstances I have concluded that it is necessary for action to be taken to prevent future deaths.
” Source location Darran Busby · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Test a workable EMIS solution and continue collaborating with EMIS on system fixes, user communication and escalation of identified risks.
Verbatim wording from the response “The Trust’s Digital Services has since engaged with EMIS in support of testing a workable solution, and have made available all resources necessary to support the work on this issue.” Source location 2022-0011-Response-from-North-Cumbria-Integrated-Care_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Return the Cockermouth Hospital community ward to the ICE Order Comms system after assessing the affected functionality.
Verbatim wording from the response “The ward at Cockermouth Hospital reverted back to using the ICE Order Comms system (ICE was outlined in the Trust’s evidence to the inquest), following an initial assessment of the functionality. Whilst this option” Source location 2022-0011-Response-from-North-Cumbria-Integrated-Care_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase Neurology team vigilance when reviewing results and stop using “file no comment” in favour of “File and Comment” to require clinician review.
Verbatim wording from the response “In the interim Dr ████████ and the Neurology team have increased vigilance when reviewing results, and have accepted the key recommendation from the Digital Services to stop using the “file no Comment” button in favour of the “File and Comment” button. This approach will introduce a direct action by the clinician that means a result cannot be filed inadvertently as a pop box always appears. This introduces extra mouse clicks and is therefore more time consuming but does provide the assurance that the results cannot be filed without appropriate review until a more robust system based solution is in place.” Source location 2022-0011-Response-from-North-Cumbria-Integrated-Care_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a separate Rad Alert system that emails referrers about significant radiology findings and escalates unacknowledged alerts to alternative clinicians.
Verbatim wording from the response “Whilst this information has been shared with EMIS to inform their consideration of solutions to this issue the Trust has sought other appropriate remedies. The Trust is implementing a Rad Alert system, which will operate separately, though alongside ICE and upon recognising an alert code in a radiology report it will email the referring consultant/GP to advise them of a significant radiology finding. In the event the email is not acknowledged within a given time period (variable according to the severity of the alert) the system will alert the rad alert admin in order that alternate clinicians can be emailed. This should prevent a recurrence of this incident regardless of whether the report is being reviewed on EMIS or on ICE as it is a separate way of highlighting the significance of the report to the referrer. It is anticipated that the RAD system will be implemented in April 2022.” Source location 2022-0011-Response-from-North-Cumbria-Integrated-Care_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Notify Primary Care colleagues using EMIS about the risk and required precautions through the CCG Chief Clinical Information Officer.
Verbatim wording from the response “The Trust has notified colleagues in Primary Care as users of EMIS through discussion with the CCG Chief Clinical Information Officer, to minimise any similar adverse action within GP provision.” Source location 2022-0011-Response-from-North-Cumbria-Integrated-Care_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue collaborating with NHS Digital on modern messaging standards to improve normal and abnormal result flagging.
Verbatim wording from the response “The UK messaging standards for laboratory and radiology reports are currently based on EDIFACT specification which are some 20 years old. EMIS is aware that NHS Digital are currently building a modern set of FHIR messaging standards which, when implemented, will enable proper level flagging of normal / abnormal findings which will significantly improve the safety of these messages; EMIS is collaborating with NHS Digital on these standards. There are no current timelines for introduction from NHS Digital.” Source location 2022-0011-Response-from-EMIS_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review results-filing training materials to emphasise detailed review of radiology and other results that may lack abnormal flags.
Verbatim wording from the response “As a result of this case and your findings, EMIS is undertaking a number of actions to support our users in the prevention of future harm:” Source location 2022-0011-Response-from-EMIS_Published
Open published response
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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 EMIS Web failsafes, combined with appropriate user diligence, are considered sufficient to prevent inadvertent filing of multiple results.
Verbatim wording from the response “In relation to any inadvertent filing activity, EMIS believe that there are sufficient failsafe measures within the system, alongside appropriate diligence from the user, to prevent such occurrence. It must be the responsibility of the clinician to review, file and subsequently archive results at a speed and with a level of diligence that fits the clinical nature of the results and the patient involved.” Source location 2022-0011-Response-from-EMIS_Published
Open published response
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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 Clinicians are responsible for reviewing, filing and archiving results at a speed and diligence appropriate to their clinical nature and patient context.
Verbatim wording from the response “In relation to any inadvertent filing activity, EMIS believe that there are sufficient failsafe measures within the system, alongside appropriate diligence from the user, to prevent such occurrence. It must be the responsibility of the clinician to review, file and subsequently archive results at a speed and with a level of diligence that fits the clinical nature of the results and the patient involved.” Source location 2022-0011-Response-from-EMIS_Published
Open published response
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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 EMIS cannot develop abnormal radiology flagging until NHS Digital standards provide identifiers distinguishing normal from abnormal results.
Verbatim wording from the response “The UK messaging standards for laboratory and radiology reports are currently based on EDIFACT specification which are some 20 years old. EMIS is aware that NHS Digital are currently building a modern set of FHIR messaging standards which, when implemented, will enable proper level flagging of normal / abnormal findings which will significantly improve the safety of these messages; EMIS is collaborating with NHS Digital on these standards. There are no current timelines for introduction from NHS Digital.” Source location 2022-0011-Response-from-EMIS_Published
Open published response
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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 Neurology Service cannot revert to ICE because transferring data from ICE to EMIS could introduce transcription errors and other risks.
Verbatim wording from the response “was explored for the Neurology Service it not a feasible solution for the service due to the potential of introducing other risks such as transcription error when transferring data from ICE to EMIS.” Source location 2022-0011-Response-from-North-Cumbria-Integrated-Care_Published
Open published response
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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 Adding flagging codes to ICE cannot affect results because source systems bypass ICE and interface directly with EMIS Web.
Verbatim wording from the response “The Trust has looked at ways of using codes to flag results via the ICE system but when the interface is linked to EMIS, the data comes directly from the source system (in this case, this would be either the Telepath Laboratory Information Management System or the GE (recently replaced by Philips) Radiology Information system). Both these systems bypass the ICE Order Comms system and interface directly with EMIS Web. Therefore, adding codes to ICE would not impact on any functionality for flagging.” Source location 2022-0011-Response-from-North-Cumbria-Integrated-Care_Published
Open published response
Concerns raised 1
Failure to implement procedures mitigating risks from failure to act on diagnostic results within the stated timeframe View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Kyle Nicholas James Hurst · 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
Kyle Nicholas James Hurst was admitted to Glan Clwyd Hospital on 24 January 2021 after taking an undisclosed quantity of a substance and died there later the same day despite treatment. Concerns included the lack of an adopted protocol for accelerated administration of N-Acetylcysteine and delays in implementing procedures intended to mitigate risks from failures to act on diagnostic 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 Failure to implement procedures mitigating risks from failure to act on diagnostic results within the stated timeframe
Wider context from the report “2. Following the issue of a regulation 28 report on the 14th of July 2021 in connection with the inquest touching upon the death of Rhian Roberts in similar circumstances, the response from BCUHB indicated by way of a letter dated the 7th of September 2021 that procedures to mitigate risks due to failure to act on diagnostic results would be approved and active by the 1st of October 2021 , however at the time of concluding the inquest of Kyle Hurst on the 22nd of October, this had not been accomplished .
” Source location Kyle Nicholas James Hurst · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the ratified procedure defining staff roles and processes for communicating critical and unexpected pathology results.
Verbatim wording from the response “In relation to the procedures to mitigate the risk of not acting upon diagnostic results, we have developed a new Procedure for the Communication of Critical and Unexpected Pathology Results. This document sets out the roles and responsibilities of staff and the process to follow. This new procedure has been ratified.” Source location 2021-0359-Response-from-BCUHB_Published
Open published response
7 Sep 2021 Roger Phelps · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Delays in returning inpatient swab results View source
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
Roger Phelps · 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
Roger Phelps was admitted to Tameside General Hospital with deteriorating cardiac function and remained on a general medical ward because a Heart Unit bed was unavailable. He contracted Covid-19 as an inpatient, developed sepsis and deteriorated before dying on 4 November 2020; post-mortem examination also identified endocarditis. The principal concern was delays of more than 48 hours in Covid-19 swab results, which could leave infectious patients on non-Covid wards and expose other patients.
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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 returning inpatient swab results
Wider context from the report “The inquest heard that whilst the trust were following PHE/NHS guidance in relation to regularity of swabbing of inpatients it was regularly taking in excess of 48 hours for swab results to be returned to the trust . The impact of the delay was that infectious asymptomatic patients were remaining on non Covid wards for some days and spreading infection to other patients .
The trust where Mr Phelps was a patient had now resolved the issue of delay results by buying additional on-site testing machines and results were back within hours rather than days.
It was unclear from evidence given at the inquest whether the issue of delayed results had been addressed by other trusts in a similar way or if the risk remained to other patients in other trusts .
” Source location Roger Phelps · Prevention of Future Deaths report
Open source report
28 Jul 2021 Jacob · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Absence of an alert and review system for ICE results across the paediatric team View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jacob · 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
Jacob died at eleven months from acute pyelonephritis, following earlier urinary tract sepsis and severe obstruction of both ureters. Investigations identifying the obstruction were not reviewed during his life, and the seriousness of a later infection was not recognised. The report identified concerns including low compliance with paediatric sepsis screening, lack of consultant review before discharge, and inadequate systems for reviewing investigation results.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of an alert and review system for ICE results across the paediatric team
Wider context from the report “3. No alert/review system for ICE results yet in place for all the Paediatric team
” Source location Jacob · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train paediatric consultants to review ICE results electronically and operate the electronic ICE system alongside a paper safety net.
Verbatim wording from the response “ICE training has taken place for all Paediatric consultants to enable them to review results electronically, and the electronic ICE system is now operational within the Paediatric department. The results are added to the folder of the requesting clinician and are available for clinicians to view electronically. The paper system remains in place as a safety net. There is a list of radiological findings that are listed in the red and amber list which leads to direct contact of the requesting clinician by the radiology team to highlight the results of an investigation. This is a failsafe system which has been in place in radiology for many years.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
Open published response
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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 Electronic ICE access, paper records and radiology red-and-amber alerts provide sufficient safeguards for reviewing paediatric investigation results.
Verbatim wording from the response “3. No alert/review system for ICE results yet in place for all the Paediatric team” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
Open published response
Concerns raised 1
Failure to approve the updated procedure for direct communication of life-threatening blood results View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Rhian Margaret Roberts · 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
Rhian Margaret Roberts was admitted to hospital after being found unresponsive at home following a presumed overdose, with extremely high paracetamol levels identified on admission. ICU clinicians did not become aware of the results until the early hours of the following morning, and she died on 25 November 2020. Concerns included uncertainty about whether a requested toxicology screen was undertaken, delays in approving an updated procedure for communicating life-threatening blood results, and delays in investigating incidents, sharing learning and implementing actions.
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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 approve the updated procedure for direct communication of life-threatening blood results
Wider context from the report “2. An internal investigation by the health board following Mrs Roberts’ death rightly established that action needed to be taken to update or modify the SOP for communicating of life-threatening blood results directly with clinical areas and an action plan indicated that this would be completed by the 30th of June 2021. At the time of the inquest on the 13th of July, the proposed update remained in draft form only and had not yet been approved .
” Source location Rhian Margaret Roberts · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update, approve and activate the SOP for telephoning reports and life-threatening results, and discuss it in team briefings.
Verbatim wording from the response “The Standard Operating Procedure (SOP) for telephoning reports and results was updated, approved and active as of the 20th July 2021 and discussed in the team brief meeting.” Source location 2021-0242-Betsi-Cadwaladr-University-Health-Board_Published
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.