Recipient

Arrowe Park HospitalIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 17 Mar 2014•Latest report 2 Jun 2014

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Arrowe Park Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: The Chief Executive, Arrowe Park Hospital.

    Wirral

    AI-generated summary

    Jennifer Morrison · 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

    Jennifer Morrison had significant breathing difficulties, fell at home on 30 December 2012, was admitted to hospital, deteriorated despite treatment, and died following a cardiac arrest on 9 January 2013. Concerns included missing hospital observation records and whether staffing pressures and delays in early January affected the care provided, including delays in transfer to a High Dependency Unit and in restarting fluids.

    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. The report was sent to Arrowe Park Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient staffing and bed capacity to maintain timely patient care during demand spikes

    Wider context from the report

    “2. Evidence was given by a Consultant Surgeon which raises concern as regards the level of care afforded to patients during the first week to ten days of January. The amount of time the Deceased spent on an assessment unit was longer than indicated by Trust guidance, which was attributed to a shortage of beds, and the higher number of patients attending the hospital after the Christmas / New Year holiday season than may be expected at other times during the year which contributed to a delay in the Deceased being treated on a High Dependency Unit. Similarly, a decision having been appropriately made that she undergo an endoscopy procedure for which she would need to remain “nil by mouth”, the Consultant acknowledged that the period of time she remained nil by mouth was “contributed to by the delay over Christmas” and that “she could have moved on to fluids sooner”, the implication again being that the number of patients waiting until after the holiday season before attending the hospital was having an impact on the staffing levels during early January and therefore on the standard of care afforded to the patients. I was concerned that the Trust could do more to ensure that the care afforded to patients was not jeopardised due to staffing levels being unable to cope with a spike in the numbers of patients waiting until after the New Year to visit hospital. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Arrowe Park Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure availability of patient observation records

    Wider context from the report

    “1. During the course of the inquest evidence was heard that there is documentation missing from the hospital medical records, notably documentation that ought to have included observations recorded by medical staff on the afternoon prior to the death. Despite reports made by the Trust, the missing documentation cannot be located. Although the inquest heard evidence that subsequent observations were noted to be at what was described as “normal levels”, it is vital that records intended to record a patient’s observations are readily available both to medical staff who continue to care for a patient, and for consideration during any subsequent post death review / investigation into events, as otherwise the integrity of such investigation may be jeopardised, potentially undermining the prospects of lessons being learnt where appropriate and future deaths may result. ”
    Open source report

  2. Addressed to: The Chief Executive, Arrowe Park Hospital.

    Liverpool

    AI-generated summary

    Charles Gavin BRADLEY · 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

    Charles Gavin Bradley fell unwitnessed in the Assessment Unit at Arrowe Park Hospital on 21 February 2013 and sustained head injuries that proved fatal. The investigation and inquest identified inadequate record-keeping and communications, including failures concerning his transfer and unclear recording of the fall.

    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. The report was sent to Arrowe Park Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of transfer communications and record-keeping

    Wider context from the report

    “During the investigation and inquest into Mr Bradley’s death it was found that the record-keeping and communications at Arrowe Park Hospital were inadequate, ineffective making them unsafe. This was evidenced by findings that though Leeds Teaching Hospital had effective records as to the arrangements for the transfer of Mr Bradley to Arrowe Park on the 21st February 2013, when Mr Bradley arrived at Arrowe Park they were not expecting him. This is likely to have caused added worry and stress to his rehabilitation plan. It is further evidenced by the inadequate recording of his fall on the 21st February 2013. From the evidence it was unclear as to whether it was witnessed or not, was it in a bathroom and if so why was there mention of a filing cabinet near he lay? In other cases the matters reported could result in fatalities. Documentation, recordkeeping and communications are core basic skills for all who work in healthcare. Neither the HEALTH aspect nor the CARE aspect of a health care service can be delivered without these basic skills. It would be helpful to see a cross Trust action plan with regard to the improving documentation, record-keeping and communication in the response to this 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. The report was sent to Arrowe Park Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate recording of patient falls

    Wider context from the report

    “During the investigation and inquest into Mr Bradley’s death it was found that the record-keeping and communications at Arrowe Park Hospital were inadequate, ineffective making them unsafe. This was evidenced by findings that though Leeds Teaching Hospital had effective records as to the arrangements for the transfer of Mr Bradley to Arrowe Park on the 21st February 2013, when Mr Bradley arrived at Arrowe Park they were not expecting him. This is likely to have caused added worry and stress to his rehabilitation plan. It is further evidenced by the inadequate recording of his fall on the 21st February 2013. From the evidence it was unclear as to whether it was witnessed or not, was it in a bathroom and if so why was there mention of a filing cabinet near he lay? In other cases the matters reported could result in fatalities. Documentation, recordkeeping and communications are core basic skills for all who work in healthcare. Neither the HEALTH aspect nor the CARE aspect of a health care service can be delivered without these basic skills. It would be helpful to see a cross Trust action plan with regard to the improving documentation, record-keeping and communication in the response to this report ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026