28 Aug 2025 Kore Elizabeth Padgett · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 3
Failure to assess the risks and benefits of collar use and support an informed decision View source Failure of ward care professionals to communicate concerns about the health impact of collar use View source Failure by those in charge of care to consider concerns about the impact of collar use 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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Kore Elizabeth Padgett · Prevention of Future Deaths report
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Report summary
Kore Elizabeth Padgett was admitted to hospital after an accidental fall down the stairs, sustaining an unstable neck fracture requiring immobilisation in a hard collar. The collar affected her swallowing, contributed to pressure sores, and limited chest physiotherapy; she later developed recurrent aspiration pneumonia and died on 23 October 2024. The concerns included inadequate staff training in fitting the collar, insufficient communication and multidisciplinary consideration of treatment options, and a lack of opportunity for Kore to make an informed decision about the risks and benefits of continued collar use.
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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 assess the risks and benefits of collar use and support an informed decision
Wider context from the report “iii) The absence of any consideration of the risks versus benefits of wearing the collar and consequently the lack of opportunity for Kore to consider the risk versus benefits and make an informed decision as to how she wanted to proceed.
” Source location Kore Elizabeth Padgett · 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 of ward care professionals to communicate concerns about the health impact of collar use
Wider context from the report “iv) The lack of communication between professionals providing care on the ward and the concerns they were raising as to the impact of the collar upon Kore's health and the absence of any consideration of those concerns by those in charge of Kore’s care with no multi-disciplinary approach as to the available treatment options or further assessments which could have been undertaken.
” Source location Kore Elizabeth Padgett · 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 by those in charge of care to consider concerns about the impact of collar use
Wider context from the report “iv) The lack of communication between professionals providing care on the ward and the concerns they were raising as to the impact of the collar upon Kore's health and the absence of any consideration of those concerns by those in charge of Kore’s care with no multi-disciplinary approach as to the available treatment options or further assessments which could have been undertaken.
” Source location Kore Elizabeth Padgett · 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 and implement a collar initiation and management procedure covering consent, risk-benefit decisions, neurosurgical input and escalation.
Verbatim wording from the response “A Standard Operating Procedure (SOP) for collar initiation and management is also being developed. This SOP will include guidance on consent, risk versus benefit, informed decision-making, collaborative input from the neurosurgical team, and clear escalation protocols. Led by Dr ████████, Matron for Surgery and Anaesthetics, the SOP will be embedded within the competency framework and is scheduled for implementation by the end of January 2026.” Source location Response from Calderdale and Huddersfield 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 Revise electronic care plans to document collar-related risk-benefit discussions and informed consent.
Verbatim wording from the response “In addition, CHFT is further embedding person-centred care principles to support informed consent when a patient has a collar in place. Led by ████████, Associate Director of Nursing for Surgery and Anaesthetics and Matron ████████, care plans are being revised to ensure that discussions around risk and benefit are documented clearly within the Electronic Patient Record (EPR). This initiative will be monitored through EPR audits and Quality Assurance Leadership walk rounds and is scheduled for completion by January 2026.” Source location Response from Calderdale and Huddersfield 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 Revise clinical guidance and protocols to establish escalation processes for advice, complications and neurosurgical liaison in cervical spine injury care.
Verbatim wording from the response “To support this pathway, CHFT guidance and protocols are being revised to provide clear escalation processes for clinical advice, complications and neurosurgical liaison and involvement relating to cervical spine injury. These revisions are being led by Dr ████████, Consultant in Care of the Elderly, and will ensure that patients are managed consistently in line with updated standards. This work is also scheduled for completion by November 2025 and is progressing as planned.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust
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26 Jul 2019 Gladys May Sayles · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 3
Inadequate guidelines for the use of Aspen collars View source Inadequate training for applying and fixing collars to patients' needs View source Ineffective communications about collar fitting and patients' general care View source
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Gladys May Sayles · Prevention of Future Deaths report
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Report summary
Gladys May Sayles was found collapsed after an unwitnessed fall at home and sustained fractures to her C2 and C3 vertebrae. She later received palliative treatment at Overgate Hospice and died there; concerns were identified about guidance, training and communication concerning the use and fitting of her hard collar.
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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 Inadequate guidelines for the use of Aspen collars
Wider context from the report “• To review the existing guidelines with respect to the use of Aspen collars .
• To review training with respect to the application and fixing of the collar in order to make it bespoke to the patient's needs.
• To consider the effectiveness of the existing communications between Leeds General neurological unit, Huddersfield Royal Infirmary and the suppliers of the collar's with respect to the fitting of the collar and patients general care.
” Source location Gladys May Sayles · 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 Inadequate training for applying and fixing collars to patients' needs
Wider context from the report “• To review the existing guidelines with respect to the use of Aspen collars.
• To review training with respect to the application and fixing of the collar in order to make it bespoke to the patient's needs .
• To consider the effectiveness of the existing communications between Leeds General neurological unit, Huddersfield Royal Infirmary and the suppliers of the collar's with respect to the fitting of the collar and patients general care.
” Source location Gladys May Sayles · 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 Ineffective communications about collar fitting and patients' general care
Wider context from the report “• To review the existing guidelines with respect to the use of Aspen collars.
• To review training with respect to the application and fixing of the collar in order to make it bespoke to the patient's needs.
• To consider the effectiveness of the existing communications between Leeds General neurological unit, Huddersfield Royal Infirmary and the suppliers of the collar's with respect to the fitting of the collar and patients general care .
” Source location Gladys May Sayles · 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 Supply each Aspen collar with applicable manufacturer instructions and leave those instructions with the patient after fitting.
Verbatim wording from the response “Guidelines in terms of the fitting of the collar are provided by the manufacturer. I enclose instruction sheets for the Aspen Collar and Aspen Vista Collar. These are the guidelines we follow.” Source location 2019-0253-Responses
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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 Maintain qualified orthotist training, probationary mentoring and mock fittings to assess competence in Aspen-collar application and fixing.
Verbatim wording from the response “To be an orthotist you need a recognised qualification from a national body called, The British Association of Prosthetists and Orthotists (BAPO). To gain this qualification you have to complete and pass a 3 year specialist course run by one of two universities – Salford and Strathclyde. During the course of that qualification the orthotist learns how fit hard collars. The BAPO website (www.bapo.com) gives further details, and confirms that:” Source location 2019-0253-Responses
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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 Complete a review of communication effectiveness between CHFT, LTHT and TayCare regarding Aspen-collar fitting and patient care.
Verbatim wording from the response “CHFT have considered the effectiveness of communication between CHFT, LTHT and TML. From the Trust perspective communication has been timely, there have been no delays from calling TML to them being on site to offer recommendations and advice, and communication with LTHT has been clear, concise and informative.” Source location 2019-0253-Responses
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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 decision to use an Aspen collar rests with Leeds Teaching Hospitals NHS Trust, not Calderdale and Huddersfield NHS Foundation Trust.
Verbatim wording from the response “CONCERN 1 – GUIDANCE RELATING TO USE OF ASPEN COLLAR:
The use of an Aspen collar for treatment in a patient with a spinal injury is a decision that is made by LTHT.” Source location 2019-0253-Responses
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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 TayCare follows manufacturer fitting guidelines and does not create clinical guidelines; treating doctors decide whether an Aspen collar is used.
Verbatim wording from the response “1. To review the existing guideline with respect to use of Aspen collars.” Source location 2019-0253-Responses
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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 Bespoke training provided by TayCare when required is considered the safest model because Calderdale and Huddersfield NHS Foundation Trust sees few Aspen-collar patients.
Verbatim wording from the response “CHFT does not offer any formal training for application of Aspen Collars; however, bespoke training is provided by TML when a patient, who requires an Aspen Collar, is being cared for under CHFT. TML will also leave written instructions with the patient in relation to the application of the Aspen Collar, which CHFT staff will follow.” Source location 2019-0253-Responses
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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 Manufacturer instructions and qualified orthotists are considered sufficient to achieve appropriate patient-specific collar fitting and training.
Verbatim wording from the response “Aspen collars are an off the shelf product. There is no bespoke element to their construction and TayCare is not involved with their construction.” Source location 2019-0253-Responses
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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 TayCare has no authority to order, arrange or provide training for NHS staff.
Verbatim wording from the response “TayCare has no power to order, arrange or give training to NHS Staff.” Source location 2019-0253-Responses
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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 Existing communication between the Trusts and TayCare is considered timely, clear, concise and informative, with no delays requiring further work.
Verbatim wording from the response “CHFT have considered the effectiveness of communication between CHFT, LTHT and TML. From the Trust perspective communication has been timely, there have been no delays from calling TML to them being on site to offer recommendations and advice, and communication with LTHT has been clear, concise and informative.” Source location 2019-0253-Responses
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29 Mar 2018 Mr Frank Hayward · Prevention of Future Deaths report Black Country
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Concerns raised 1
Poor systems for providing patient collars 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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Mr Frank Hayward · 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 Frank Hayward fell at home on 12 November 2017, sustaining an odontoid peg fracture and subdural haemorrhage, and died on 10 December 2017 after his condition declined. The concerns included failures to correctly assess and diagnose his injuries, delays in Trauma and Orthopaedics review and urgent CT scanning, and poor systems and communication in obtaining a cervical collar.
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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 Poor systems for providing patient collars
Wider context from the report “2. There was also evidence of poor systems in place in providing a collar for the patient and poor communication between the Orthotics Department and ward based staff. In addition there was a significant delay in obtaining an urgent CT scan.
” Source location Mr Frank Hayward · 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 Train Trauma and Orthopaedics clinicians to apply Miami J collars out of hours.
Verbatim wording from the response “Clinicians from Trauma & Orthopaedics have, since this incident, been trained in the application of Miami J collars, enabling patients to be fitted out of hours in future. A stock of Miami J collars is held on our T&O ward (Newton 3) and this is checked and replenished daily by the Orthotics team.” Source location Frank-Hayward-Response
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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 Hold and daily replenish a stock of Miami J collars on the Newton 3 ward.
Verbatim wording from the response “Clinicians from Trauma & Orthopaedics have, since this incident, been trained in the application of Miami J collars, enabling patients to be fitted out of hours in future. A stock of Miami J collars is held on our T&O ward (Newton 3) and this is checked and replenished daily by the Orthotics team.” Source location Frank-Hayward-Response
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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 Provide all Sandwell General Hospital wards with Orthotics contact details and substantive administrative support for timely referrals.
Verbatim wording from the response “At the time when Mr Hayward required a collar, the Orthotics Department was in the process of relocating onto the Sandwell General Hospital (SGH) site. This move, together with issues of transfer of telephone numbers and locum staff, delayed the referral being received and acted upon. All wards at SGH now have the contact details (number and email address) of the Orthotics Department to ensure contact is timely, with substantive administrative staff in place. Business Continuity plans are in place but are being reviewed to take account of staffing levels, given that this was a concern at the time of Mr Haywards admission.” Source location Frank-Hayward-Response
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28 Apr 2014 Mr Robert Anthony Perkins · Prevention of Future Deaths report Avon
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Concerns raised 3
Failure to raise concerns about inadequate neck immobilisation View source Failure to properly immobilise the neck of patients with cervical spine fractures View source Unavailability of suitable cervical collars View source
Linked response
Bristol 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. 5
Bristol NHS Foundation Trust
Clarify handover communication when a rigid collar is not applied, including reasons, interim neck-care requirements and reattempt timing.
View source
Bristol NHS Foundation Trust
Re-publicise the hard-collar safety alert across the Medical Directorate and Trustwide clinical directorates.
View source
Bristol NHS Foundation Trust
Include the hard-collar safety alert in future medical induction for new junior medical staff.
View source
Bristol NHS Foundation Trust
Report the Regulation 28 findings to the Medical Directorate’s clinical governance agenda.
View source
Bristol NHS Foundation Trust
Establish a central Emergency Zone storage location for rigid cervical collars.
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AI-generated summary
Mr Robert Anthony Perkins · 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 Robert Anthony Perkins, who had terminal cancer, was admitted after a fall and was found to have a cervical spine fracture. Despite neurosurgical instructions, a cervical collar was not fitted while he was on the ward, and a suitable collar was difficult to obtain before his transfer to a hospice, where he died. The report raised concerns that inadequate immobilisation placed him at risk of serious or fatal injury and that suitable collars were not readily available.
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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 raise concerns about inadequate neck immobilisation
Wider context from the report “(1) Notwithstanding the instructions of the neurosurgeons no effort was made to obtain and fit a cervical collar throughout the time he was on the ward. It was fortuitous that the patient did not suffer neurological injury. However, he was at risk of serious injury and death as a consequence of the failure to immobilise the neck.
(3) Other than the Specialist Registrar no concerns were raised by medical staff that the patient's neck was not properly immobilised both on the ward and on discharge .
(4) The hospital is a regional centre for neurosciences and neurosurgery yet the prescribed cervical collar was not available and the Registrar had difficulty locating a suitable collar.
(5) The failure to properly immobilise the neck of patients with fractures of the cervical spine, whether on the instructions of neurosurgeons or otherwise, could place those patients at risk of significant and disabling injury and death.
” Source location Mr Robert Anthony Perkins · 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 properly immobilise the neck of patients with cervical spine fractures
Wider context from the report “(1) Notwithstanding the instructions of the neurosurgeons no effort was made to obtain and fit a cervical collar throughout the time he was on the ward . It was fortuitous that the patient did not suffer neurological injury. However, he was at risk of serious injury and death as a consequence of the failure to immobilise the neck .
(3) Other than the Specialist Registrar no concerns were raised by medical staff that the patient's neck was not properly immobilised both on the ward and on discharge.
(4) The hospital is a regional centre for neurosciences and neurosurgery yet the prescribed cervical collar was not available and the Registrar had difficulty locating a suitable collar.
(5) The failure to properly immobilise the neck of patients with fractures of the cervical spine , whether on the instructions of neurosurgeons or otherwise, could place those patients at risk of significant and disabling injury and death.
” Source location Mr Robert Anthony Perkins · 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 Unavailability of suitable cervical collars
Wider context from the report “(1) Notwithstanding the instructions of the neurosurgeons no effort was made to obtain and fit a cervical collar throughout the time he was on the ward. It was fortuitous that the patient did not suffer neurological injury. However, he was at risk of serious injury and death as a consequence of the failure to immobilise the neck.
(3) Other than the Specialist Registrar no concerns were raised by medical staff that the patient's neck was not properly immobilised both on the ward and on discharge.
(4) The hospital is a regional centre for neurosciences and neurosurgery yet the prescribed cervical collar was not available and the Registrar had difficulty locating a suitable collar .
(5) The failure to properly immobilise the neck of patients with fractures of the cervical spine, whether on the instructions of neurosurgeons or otherwise, could place those patients at risk of significant and disabling injury and death.
” Source location Mr Robert Anthony Perkins · 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 Clarify handover communication when a rigid collar is not applied, including reasons, interim neck-care requirements and reattempt timing.
Verbatim wording from the response “It is clear that communication of these issues is vital to prevent a recurrence of a similar case. It is agreed that communication should include, where there is a failure to apply a rigid collar in the ED, the reasons why the collar was not applied and the nursing aspects for the neck in the interim and when a reattempt at applying the collar should occur.” Source location 2014-0195-Response-by-North-Bristol-NHS-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 Re-publicise the hard-collar safety alert across the Medical Directorate and Trustwide clinical directorates.
Verbatim wording from the response “Following the inquest the Clinical Director (CD) of the Medicine Directorate discussed this case with his neurosurgical colleagues, in particular awareness and understanding regarding the use of collars. I enclose a hard collar safety alert dated October 2011. The CD will re-publicise this issue by sending this alert out again to the Medical Directorate, and to other CDs to ensure that there is Trustwide distribution in the few days also and include it in future medical induction of new junior medical staff (the next one will be in August 2014).” Source location 2014-0195-Response-by-North-Bristol-NHS-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 Include the hard-collar safety alert in future medical induction for new junior medical staff.
Verbatim wording from the response “Following the inquest the Clinical Director (CD) of the Medicine Directorate discussed this case with his neurosurgical colleagues, in particular awareness and understanding regarding the use of collars. I enclose a hard collar safety alert dated October 2011. The CD will re-publicise this issue by sending this alert out again to the Medical Directorate, and to other CDs to ensure that there is Trustwide distribution in the few days also and include it in future medical induction of new junior medical staff (the next one will be in August 2014).” Source location 2014-0195-Response-by-North-Bristol-NHS-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 Report the Regulation 28 findings to the Medical Directorate’s clinical governance agenda.
Verbatim wording from the response “The regulation 28 report will also be reported on in part B of the Medical Directorate’s clinical governance agenda on 26 June 2014. From here it will be decided on whether any further action needs to be taken. Following this, it is likely that a further notification will be made to the directorate’s medical teams to ensure that they are all familiar with the need to review plans for cervical immobilisation when a patient is admitted with a cervical neck injury and the location of the rigid collar devices.” Source location 2014-0195-Response-by-North-Bristol-NHS-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 Establish a central Emergency Zone storage location for rigid cervical collars.
Verbatim wording from the response “The accessibility of rigid collars for the purposes of cervical immobilisation is something that is also being addressed now since the move into the new Brunel building. A place for central storage of these devices is being looked for within the Emergency Zone. By creating a single area for the location of these devices it should make it easier to know where to find a collar when the device is needed. It is anticipated that this action should be completed by the end of June 2014.” Source location 2014-0195-Response-by-North-Bristol-NHS-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 Further collar application was not pursued because the patient could not tolerate collars and persistence or sedation risked causing greater harm and distress.
Verbatim wording from the response “From investigations it appears that whilst in the Emergency Department (ED) Mr Perkins was too agitated to wear a rigid collar and persistence in trying to put a collar on or even just wearing a collar would likely to have caused more harm and distress to him. Also the ED consultant felt it inappropriate to sedate Mr Perkins for the purposes of applying the collar, again due to the risks of harm from sedation.” Source location 2014-0195-Response-by-North-Bristol-NHS-Trust
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.