Recurring concern

Unsafe recognition and escalation of bowel obstruction

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First reported 14 Apr 2016•Latest report 19 Sep 2025

Definition

What this concern includes

Includes failures of the dedicated bowel-obstruction diagnostic, monitoring, assessment or escalation pathway, including failure to recognise symptoms, warning signs or clinical indicators of obstruction or its complications.

Not included

Excludes generic staff training deficiencies that are not specifically tied to recognising or managing bowel obstruction.
Excludes failures concerning other clinical conditions or hazards, even where they involve similar recognition or escalation mechanisms.
Excludes isolated documentation, staffing or communication failures unless they directly impair the bowel-obstruction recognition, monitoring or escalation pathway.

Reports: 5
Individual concerns: 5
Date range: 2016–2025
Stated actions: 2

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Ashford and St Peter'S Hospitals NHS Foundation Trust1

Croydon University Hospital1

Department of Health and Social Care1

East Kent Hospitals University NHS Foundation Trust1

Medicines and Healthcare products Regulatory Agency1

Royal College of Emergency Medicine1

Royal College of Psychiatrists1

South London and Maudsley NHS Foundation Trust1

Tameside and Glossop Integrated Care NHS Foundation Trust1

The Queen Elizabeth Hospital, King's Lynn1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

19 Sep2025
South London
Concerns raised1
1. Failure to identify the risks of deterioration and death from suspected acute obstruction in patients chronically on Clozapine
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr Luke John Chatterton · 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 Luke John Chatterton had a history of Clozapine-related constipation and developed vomiting, severe pain and suspected intestinal obstruction. He was discharged from the emergency department after an X-ray, later deteriorated and suffered a cardiac arrest, with delays in advanced life support before he died. The principal concerns were the safety and timeliness of resuscitation for detained mental health patients and the identification and escalation of risks associated with suspected obstruction in patients taking Clozapine.

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 identify the risks of deterioration and death from suspected acute obstruction in patients chronically on Clozapine
Wider context from the report
“2. The acute Trust has taken a number of steps to facilitate identifying the risks of a patient who is referred with suspected obstruction. Outstanding is the development with the mental health Trust of an educational package and guidelines for managing suspected acute obstruction, including pseudo-obstruction (a complication of Clozapine) and recognizing the rare but potentially fatal risks of anti-psychotics. There is currently no national formal guideline on management of bowel obstruction. Given the rarity of antipsychotic induced acute obstruction, there seems to be merit in alerting national professional bodies to enable consideration to be given to the development of a guideline, which might identify the use of red flags to escalate and investigate those at most risk. ”
Source location
Mr Luke John Chatterton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Jul2024
Surrey
Concerns raised1
1. Failure to recognise rising CRP as a potential indicator of ischaemia during conservative management of small bowel obstruction
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Support and oversee clinical training on observations, NEWS2 scoring, escalation, and abnormal blood-result recognition including CRP.
  Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated in progress
2. Action
  Monitor deterioration-recognition and escalation quality-improvement projects, including senior review, critical-care referral, and abnormal-result escalation.
  Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated in progress
AI-generated summary

Wendy HAMMON · 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 Wendy Hammon was admitted to hospital on 30 August 2022 with abdominal pain, vomiting and a small bowel obstruction caused by adhesions from previous surgery. She developed mesenteric ischaemia and multi-organ failure and died on 9 September 2022. The court was concerned that rising CRP was not recognised, fluid input and output charts were inadequate, and NEWS2 scores were often incomplete, with no reassurance that these matters had been addressed.

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 recognise rising CRP as a potential indicator of ischaemia during conservative management of small bowel obstruction
Wider context from the report
“1. Mrs Hammon’s rising CRP was not noted by any member of the clinical team – whether junior or senior - who saw Mrs Hammon during the period from 1 September onwards, despite rising CRP being a potential indicator of ischaemia in patients who are being conservatively managed for small bowel obstruction. The court is concerned that this was not an individual error and may be reflective of a wider lack of knowledge within the team. ”
Source location
Wendy HAMMON · Prevention of Future Deaths report
Page 6 · 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
Support and oversee clinical training on observations, NEWS2 scoring, escalation, and abnormal blood-result recognition including CRP.

Verbatim wording from the response
“A Trust wide Deteriorating Patient Working Group has recently commenced to address concerns around recognising, escalating, and managing the deteriorating patient. The group has representation from all clinical areas, medical, nursing, and allied health professionals, practice educators and training leads, and digital leads. The group is focussed on leading improvements in the following areas.”

Source location
Response from Ashford and St Peter's Hospitals
Page 3 · response
Published 5 August 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Monitor deterioration-recognition and escalation quality-improvement projects, including senior review, critical-care referral, and abnormal-result escalation.

Verbatim wording from the response
“A Trust wide Deteriorating Patient Working Group has recently commenced to address concerns around recognising, escalating, and managing the deteriorating patient. The group has representation from all clinical areas, medical, nursing, and allied health professionals, practice educators and training leads, and digital leads. The group is focussed on leading improvements in the following areas.”

Source location
Response from Ashford and St Peter's Hospitals
Page 3 · response
Published 5 August 2024
Open published response
21 Dec2018
Norfolk
Concerns raised1
1. Failure to recognise and act on warning signs of bowel obstruction
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

William Clifford ATHERTON · 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

William Clifford Atherton was admitted to hospital on 29 May 2017 with abdominal symptoms, urinary retention and poor kidney function. He was discharged despite worsening renal function and deterioration, and died after returning severely unwell with vomiting of faecal matter, a distended abdomen and severe pain; the reported cause was bowel obstruction. Concerns included the lack of senior medical review and nursing observations, failure to recognise warning signs and worsening blood results, and inconsistent early warning score documentation and escalation.

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 recognise and act on warning signs of bowel obstruction
Wider context from the report
“That no medical review of Mr Atherton took place after the ward round on 30th. That his worsening condition was not recognised by the junior doctor reviewing the blood results. That no nursing observations were carried out in the several hours whilst he waited to go home and that potential warning signs of a bowel obstruction were not recognised and acted upon. His documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place. That the different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it. ”
Source location
William Clifford ATHERTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Jun2016
Manchester South
Concerns raised1
1. Failure to train staff to recognise blocked-bowel symptoms and their seriousness
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

David Michael little · 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 Michael Little was admitted to hospital with abdominal pain and a suspected small-bowel mass. His condition worsened, and a scan revealed a blockage caused by ischaemic bowel; delays in scanning, reporting, and insertion of an NG tube meant that surgery was considered when it was deemed too late. The report raised concerns about poor record-keeping, lack of a clear diagnostic and monitoring pathway, failure to recognise the seriousness of bowel obstruction, and poor communication among staff and with the family.

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 train staff to recognise blocked-bowel symptoms and their seriousness
Wider context from the report
“2. The hospital had no clear diagnostic pathway or monitoring plan on admission, the staff appeared not to be trained to recognise the symptoms of a blocked bowel nor the potential seriousness thereof nor to be aware of the dire consequences of failure to diagnose and treat appropriately. ”
Source location
David Michael little · Prevention of Future Deaths report
Page 1 · concerns
Open source report
14 Apr2016
Central and South East Kent
Concerns raised1
1. Delay in confirming sigmoid colon obstruction diagnosis
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Helen Jennifer Turner · 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

Helen Jennifer Turner was admitted with diarrhoea and vomiting and was diagnosed with a sigmoid colon obstruction. She later developed sepsis, colonic perforation and peritonitis, underwent surgery and further procedures, and died after her condition deteriorated. The report identified delays in confirming the obstruction, arranging stenting and operating to remove it; expert evidence stated that these delays diminished her chances of survival.

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
Delay in confirming sigmoid colon obstruction diagnosis
Wider context from the report
“• There was a delay in confirming the diagnosis of sigmoid colon obstruction which did not take place until 12.04.15, some four days after her admission to William Harvey Hospital. ”
Source location
Helen Jennifer Turner · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to identify the risks of deterioration and death from suspected acute obstruction in patients chronically on Clozapine

Concerns raised1

Failure to recognise rising CRP as a potential indicator of ischaemia during conservative management of small bowel obstruction

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to recognise and act on warning signs of bowel obstruction

Concerns raised1

Failure to train staff to recognise blocked-bowel symptoms and their seriousness

Concerns raised1

Delay in confirming sigmoid colon obstruction diagnosis

Actions described in response 2