Recurring concern

Unreliable communication with original treating teams after post-procedure readmission

First to latest report 4 Jun 2025 — 10 Oct 2025

Reports that mention this concern
2
Times this concern has been raised
3
Stated actions linked to this concern
3

What this concern includes

Includes failures in the dedicated process for notifying, contacting or consulting the original treating team or department when a patient is readmitted after a recent procedure or develops a related complication, including absence of required contact procedures and failure to seek the treating team's advice.

What is not included
  • Excludes generic clinical communication or record-transfer failures that are not specifically connected to readmission after a recent procedure or a related procedure complication.
  • Excludes failures to communicate with primary care, families or unrelated specialist services where the original treating team or department is not the relevant recipient.
  • Excludes delays in treatment, theatre access or transfer after the original treating team has been appropriately informed.
  • Excludes failures concerning routine postoperative follow-up or complications where no deficient readmission communication or contact process is identified.

Reports and published responses 2 reports

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

  1. Lancashire and Blackburn with Darwen

    AI-generated summary

    Adrienne Caroline STUDHOLME · 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

    Adrienne Caroline STUDHOLME died on 23 September 2023 at Royal Blackburn Hospital after readmission following a left nephrectomy, with a spontaneous splenic haemorrhage and rupture identified later that day and subsequent myocardial infarction. The report states that her death was contributed to by a delay in diagnosing and treating the splenic rupture. Concerns included inaccurate fluid-balance charts, seizure activity not being considered unless witnessed by staff, and the absence of procedures, standard operating practice, and training to ensure recent surgery was considered and communicated during emergency-department triage.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a procedure requiring contact with the original treating department on readmission after recent surgery

    Wider context from the report

    “(3) Evidence was heard that on readmission via the Emergency Department following recent surgery, there is no procedure requiring contact with the original treating department. In addition, there is no standard operating practice and no training ensuring that recent surgery is taken into account in a triage in the Emergency department. ”

    Source location

    Adrienne Caroline STUDHOLME · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Remind Emergency Department and surgical clinicians to urgently contact the surgical team when clinical judgement indicates a possible surgical complication.

    Verbatim wording from the response

    “It is accepted, however, that where clinical judgement indicates the possibility that a direct surgical complication may have arisen, then urgent contact with the surgical team is essential. Clinicians from the ED have been reminded of the importance of this, and clinicians from the surgical teams of the importance of prompt response. Indeed, a revised version of our internal professional standards for response has been developed, and the Trust commits to monitor these once implemented.”

    Source location

    Response from East Lancashire NHS Trust
    Page 2 · response
    Published 14 October 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop revised internal professional standards for response to support prompt surgical-team responses.

    Verbatim wording from the response

    “It is accepted, however, that where clinical judgement indicates the possibility that a direct surgical complication may have arisen, then urgent contact with the surgical team is essential. Clinicians from the ED have been reminded of the importance of this, and clinicians from the surgical teams of the importance of prompt response. Indeed, a revised version of our internal professional standards for response has been developed, and the Trust commits to monitor these once implemented.”

    Source location

    Response from East Lancashire NHS Trust
    Page 2 · response
    Published 14 October 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Routine contact with the original surgical department after readmission is not considered necessary where the presenting problem appears unrelated to previous surgery.

    Verbatim wording from the response

    “The third area of concern is that there is currently no process for patient’s who present to the Emergency Department following recent surgery to be seen by the original treating department. This is not amenable to a simple procedure – a referral in the context of a problem unrelated to the surgery, where the surgical team may not have expertise related to that condition, would be both futile and add complexity. In this case the initial presentation did not indicate any link with the previous procedure during triage.”

    Source location

    Response from East Lancashire NHS Trust
    Page 2 · response
    Published 14 October 2025

    Open published response

  2. Essex

    AI-generated summary

    DAVID HEFFER · 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 Heffer died on 13 April 2024 from septicaemia due to acute peritonitis following duodenal and omental perforation after an ERCP performed for obstructive jaundice. He was discharged on the day of the procedure and readmitted the next day in severe pain with biliary sepsis and perforation. Concerns included failure to inform the treating doctor of the readmission and incomplete or illegible medical records.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to inform the treating doctor of readmission with a procedure complication

    Wider context from the report

    “(1) The treating doctor was not informed when Mr Heffer was readmitted with a complication of the ERCP procedure, and his advice was not sought about potential causes of the complication. The treating doctor only found out about the readmission on contact from coroner’s office. ”

    Source location

    DAVID HEFFER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to seek treating-doctor advice about potential causes of complications

    Wider context from the report

    “(1) The treating doctor was not informed when Mr Heffer was readmitted with a complication of the ERCP procedure, and his advice was not sought about potential causes of the complication. The treating doctor only found out about the readmission on contact from coroner’s office. ”

    Source location

    DAVID HEFFER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Reinforce informing procedural endoscopists about ERCP complications through team reminders, handover guidance and clinical education.

    Verbatim wording from the response

    “The Trust acknowledges the need for better communication between clinicians. Reminders will be provided to all general surgical teams, who remain the primary team managing ERCP-related complications, as agreed unanimously at the regional ERCP Clinical Delivery Group—that where feasible, the procedural endoscopist should be informed of any complication arising from an ERCP they performed. The expectation is that a phone call should be made to inform the procedural endoscopist of the readmission. Informing procedural endoscopists of any complication arising from an ERCP they performed will be included in departmental handover guidance and reinforced through clinical education sessions.”

    Source location

    Response from East Suffolk and North Essex NHS Foundation Trust
    Page 2 · response
    Published 11 June 2025

    Open published response

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

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Data last updated 7 September 2026