8 Aug 2024 Mrs Gillian Patricia Stokes · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Lack of clinical guidance for recognising possible radiation-induced sarcoma View source Failure to clearly communicate required follow-up to families View source Lack of protocols for first-line investigation of patients with breast implants after radiotherapy View source Failure to complete scheduled two-week follow-up after aspiration View source Insufficient duration of surveillance for radiation-induced sarcoma after breast cancer View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mrs Gillian Patricia Stokes · 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 Gillian Patricia Stokes died from sarcoma of the right chest wall after previously receiving radiotherapy for breast cancer and having breast reconstructive surgery with an implant. The report raises concerns about insufficient guidance for identifying radiation-induced sarcoma and imaging the chest wall in patients with implants, the five-year surveillance period after breast cancer, and the failure to arrange a recommended two-week follow-up after aspiration.
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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. The report was sent to Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical guidance for recognising possible radiation-induced sarcoma
Wider context from the report “(1) I am concerned that there is not any or insufficient guidance available to clinicians in regard to possible radiation induced sarcoma , or first line investigations for patients with breast implants to be able to see down to the chest wall. The Radiologist, Surgeon and Nurse advised that they did not have any specific guidance in relation to possible radiation-induced sarcoma ,
████████from the Royal Marsden advised in written evidence, that radiation induced sarcomas are increasing in incidence as more primary breast cancer patients are now offered breast conserving surgery with wide local excision and radiotherapy, rather than mastectomy alone (previously there was no radiation). Therefore, in his view the increasing use of radiotherapy leads to increased number of patients developing radiation induced sarcomas. As ████████ said from the Royal Marsden, diagnosis requires the treating clinician to recognise that this is a possibility .
Furthermore, as ████████ advised in his experience the difficulties in diagnosis are that they are sometimes not recognised by primary and secondary care teams who are the first to see the patient .
In evidence the Radiologist confirmed that the Royal College of Radiologists do not have a protocol for patients who have had previous radiotherapy and implant. Furthermore, Nurse Diagnostician confirmed there was no protocol in the ABS Best Practice Diagnostic Guidelines for radiation induced sarcoma where a patient has had an implant.
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly communicate required follow-up to families
Wider context from the report “(3) I have concerns regarding the system in place at Ashford Hospital for 2 week follow ups following an aspiration following an initial assessment at the One Stop Clinic. Following the aspiration Mrs Stokes received, the Nurse advised in evidence Mrs Stokes should have had a further review after two weeks, as indicated in the paperwork, but this was not followed through by the hospital and the message was not clearly communicated to the family . This would have allowed for further follow up in case the bulge had increased in size and in pain and could have potentially identified the need to investigate further.
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols for first-line investigation of patients with breast implants after radiotherapy
Wider context from the report “(1) I am concerned that there is not any or insufficient guidance available to clinicians in regard to possible radiation induced sarcoma, or first line investigations for patients with breast implants to be able to see down to the chest wall . The Radiologist, Surgeon and Nurse advised that they did not have any specific guidance in relation to possible radiation-induced sarcoma,
████████from the Royal Marsden advised in written evidence, that radiation induced sarcomas are increasing in incidence as more primary breast cancer patients are now offered breast conserving surgery with wide local excision and radiotherapy, rather than mastectomy alone (previously there was no radiation). Therefore, in his view the increasing use of radiotherapy leads to increased number of patients developing radiation induced sarcomas. As ████████ said from the Royal Marsden, diagnosis requires the treating clinician to recognise that this is a possibility.
Furthermore, as ████████ advised in his experience the difficulties in diagnosis are that they are sometimes not recognised by primary and secondary care teams who are the first to see the patient.
In evidence the Radiologist confirmed that the Royal College of Radiologists do not have a protocol for patients who have had previous radiotherapy and implant . Furthermore, Nurse Diagnostician confirmed there was no protocol in the ABS Best Practice Diagnostic Guidelines for radiation induced sarcoma where a patient has had an implant .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete scheduled two-week follow-up after aspiration
Wider context from the report “(3) I have concerns regarding the system in place at Ashford Hospital for 2 week follow ups following an aspiration following an initial assessment at the One Stop Clinic . Following the aspiration Mrs Stokes received, the Nurse advised in evidence Mrs Stokes should have had a further review after two weeks, as indicated in the paperwork, but this was not followed through by the hospital and the message was not clearly communicated to the family. This would have allowed for further follow up in case the bulge had increased in size and in pain and could have potentially identified the need to investigate further.
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient duration of surveillance for radiation-induced sarcoma after breast cancer
Wider context from the report “(2) I have a concern regarding the current surveillance period of 5 years provided to patients with breast cancer considering the latency period of radiation induced sarcoma is 10 years .
” 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 Review the One Stop Shop breast clinic appointments process.
Verbatim wording from the response “With regards to matter of concern 3, the Trust has reviewed the appointments process within the One Stop Shop breast clinic and has found the following:” Source location Response from Ashford and St Peter's Hospitals NHS Foundation Trust
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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 Develop and finalise a standard operating procedure standardising Breast One Stop Shop Clinic follow-up, including earlier review where needed, and provide it to the court.
Verbatim wording from the response “The Division is in the process of developing a Standard Operating Procedure (SOP) for the Breast One Stop Shop Clinic, which will outline the guidelines for patient follow-up care. The aim of this SOP is to create a follow-up process that is both standardised and tailored to individual patient needs. The process will accommodate patients requiring earlier follow-up in some circumstances. Once the SOP has been finalised, a copy will be provided to the court for information and assurance.” Source location Response from Ashford and St Peter's Hospitals NHS Foundation Trust
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 Matters of concern 1 and 2 will be addressed by the President of the Royal College of Radiologists.
Verbatim wording from the response “I understand that the Regulation 28 report has also been sent to the President of the Royal College of Radiologists who will respond to matters of concern 1 and 2.” Source location Response from Ashford and St Peter's Hospitals NHS Foundation Trust
Open published response
30 Jul 2024 Wendy HAMMON · Prevention of Future Deaths report Surrey
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Concerns raised 3 Failure to recognise rising CRP as a potential indicator of ischaemia during conservative management of small bowel obstruction View source Inadequate recording of fluid input and output View source Incomplete recording of Early Warning Scores (NEWS2 Scores) View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 13
Action
Monitor deterioration-recognition and escalation quality-improvement projects, including senior review, critical-care referral, and abnormal-result escalation.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2024. View source
Action
Support and oversee clinical training on observations, NEWS2 scoring, escalation, and abnormal blood-result recognition including CRP.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2024. View source
Action
Set ward times for recording catheter, drain, and nasogastric-tube outputs and monitor chart-review compliance.
Stated completedThe respondent said that this action was complete when they made their response on 5 August 2024. View source
Action
Disseminate a quick reference guide explaining how to manage parenteral nutrition entries in the electronic fluid-balance chart.
Stated completedThe respondent said that this action was complete when they made their response on 5 August 2024. View source
Action
Provide ward-focused tea-trolley education on accurate fluid-balance recording.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2024. View source
Action
Carry out a ward quality-improvement project to improve oral hydration and fluid balance.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2024. View source
Action
Reinforce fluid-balance practice through daily safety huddles and recurring ward handover topics.
Stated completedThe respondent said that this action was complete when they made their response on 5 August 2024. View source
Action
Conduct a gap analysis to identify updates needed to improve fluid-balance-chart accessibility and viewing.
Stated plannedThe respondent said that this action was planned when they made their response on 5 August 2024. View source
Action
Conduct the electronic fluid-balance discovery work with subject-matter experts to define required data feeds.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2024. View source
Action
Review fluid-balance charts during weekly senior-nurse care rounds.
Stated completedThe respondent said that this action was complete when they made their response on 5 August 2024. View source
Action
Review and update policies and guidance for recognising, escalating, and managing deteriorating patients and sepsis.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2024. View source
Action
Review and strengthen electronic-record sepsis and NEWS2 escalation tools and alerts.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2024. View source
Action
Provide fluid-balance recording training through induction, student workbooks, preceptorship, and ward-based clinical education.
Stated completedThe respondent said that this action was complete when they made their response on 5 August 2024. View source See 10 more actions
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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.
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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. The report was sent to Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
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 .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of fluid input and output
Wider context from the report “2. The fluid input and output charts completed for Mrs Hammon were inadequate and could not be relied upon to accurately assess her fluid input and output .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete recording of Early Warning Scores (NEWS2 Scores)
Wider context from the report “3. The Early Warning Scores (NEWS2 Scores) for Mrs Hammon were often incomplete .
” 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 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
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 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
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 Set ward times for recording catheter, drain, and nasogastric-tube outputs and monitor chart-review compliance.
Verbatim wording from the response “One ward has implemented a set time for emptying catheters, drains, and NG tubes to ensure output is recorded. Staff are expected to review charts before the end of each shift and the ward manager is monitoring compliance with this. The ward is also working on a quality improvement project to improve patient oral hydration and fluid balance. Both of these quality improvement initiatives will be rolled out across the Trust once their benefit and success are evaluated.” Source location Response from Ashford and St Peter's Hospitals
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 Disseminate a quick reference guide explaining how to manage parenteral nutrition entries in the electronic fluid-balance chart.
Verbatim wording from the response “It was identified that the fluid balance area of the EPR does not automatically populate the fluid balance chart when parenteral nutrition is commenced. To manage this a quick reference guide (QRG) - appendix 1 - was developed and widely disseminated throughout the Trust. Fluid Management is a high priority on the list of projects for the Medication Administration Process within EPR which will commence in October 2024 following an EPR system upgrade. The Electronic Prescribing and Medicines Administration (EPMA) Pharmacists are undertaking work as part of a Discovery Phase to provide the EPR team with the fullest information to enable them to proceed. The EPR team will work with Subject Matter Experts (SME) to understand what needs to feed through to the fluid balance chart.” Source location Response from Ashford and St Peter's Hospitals
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 Provide ward-focused tea-trolley education on accurate fluid-balance recording.
Verbatim wording from the response “The divisional Clinical Practice Educators are providing ward focused education in the form of tea trolley training to ensure all staff are educated in the accurate recording of fluid balance.” Source location Response from Ashford and St Peter's Hospitals
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 Carry out a ward quality-improvement project to improve oral hydration and fluid balance.
Verbatim wording from the response “One ward has implemented a set time for emptying catheters, drains, and NG tubes to ensure output is recorded. Staff are expected to review charts before the end of each shift and the ward manager is monitoring compliance with this. The ward is also working on a quality improvement project to improve patient oral hydration and fluid balance. Both of these quality improvement initiatives will be rolled out across the Trust once their benefit and success are evaluated.” Source location Response from Ashford and St Peter's Hospitals
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 Reinforce fluid-balance practice through daily safety huddles and recurring ward handover topics.
Verbatim wording from the response “The importance of fluid balance has been discussed at daily safety huddles across the wards. This has also been a focus of the ward’s ‘Big 3’ where three important topics that are the focus for a week are discussed at all handovers and will be repeated at intervals until embedded in practice.” Source location Response from Ashford and St Peter's Hospitals
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 Conduct a gap analysis to identify updates needed to improve fluid-balance-chart accessibility and viewing.
Verbatim wording from the response “A gap analysis will follow this to identify the updates needed to improve the accessibility and the viewing of the fluid balance chart. A secondary project to implement clinical support decisions to help the identification of patients who are at risk of hydration or renal issues will also be required.” Source location Response from Ashford and St Peter's Hospitals
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 Conduct the electronic fluid-balance discovery work with subject-matter experts to define required data feeds.
Verbatim wording from the response “It was identified that the fluid balance area of the EPR does not automatically populate the fluid balance chart when parenteral nutrition is commenced. To manage this a quick reference guide (QRG) - appendix 1 - was developed and widely disseminated throughout the Trust. Fluid Management is a high priority on the list of projects for the Medication Administration Process within EPR which will commence in October 2024 following an EPR system upgrade. The Electronic Prescribing and Medicines Administration (EPMA) Pharmacists are undertaking work as part of a Discovery Phase to provide the EPR team with the fullest information to enable them to proceed. The EPR team will work with Subject Matter Experts (SME) to understand what needs to feed through to the fluid balance chart.” Source location Response from Ashford and St Peter's Hospitals
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 Review fluid-balance charts during weekly senior-nurse care rounds.
Verbatim wording from the response “Review of fluid balance charts forms part of the weekly care round where senior nurses visit each ward providing support and guidance in completing all aspects of the patient’s EPR.” Source location Response from Ashford and St Peter's Hospitals
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 Review and update policies and guidance for recognising, escalating, and managing deteriorating patients and sepsis.
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
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 Review and strengthen electronic-record sepsis and NEWS2 escalation tools and alerts.
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
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 Provide fluid-balance recording training through induction, student workbooks, preceptorship, and ward-based clinical education.
Verbatim wording from the response “New clinical staff to the Trust have training in accurate monitoring of fluid balance as part of the induction training (for Health Care Support Workers, newly registered nurses, and Internationally Educated Nurses). This training forms part of the Care Certificate for Health Care support workers and the Preceptorship competencies of newly registered nurses and internationally educated nurses. Student Nurses allocated to the Trust receive additional training on induction which consists of a workbook that includes how to complete fluid charts and the importance of accurate fluid balance records for patient care. Ward based Clinical Practice Educators work alongside staff with all aspects of nursing care including accurate recording of fluid balance and how to record this on the EPR.” Source location Response from Ashford and St Peter's Hospitals
Open published response
23 May 2019 Sasha Sabrina FORSTER · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 6 Risk of using prescribed Propranolol for overdose View source Failure to agree and update a common action plan for revoked s.17 leave View source Failure to collect and return patients to the ward when s.17 leave is revoked View source Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol View source Failure to finalise the formal revocation of s.17 leave View source Lack of shared awareness of powers and responsibilities when s.17 leave is revoked View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sasha Sabrina FORSTER · 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
Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.
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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of using prescribed Propranolol for overdose
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to agree and update a common action plan for revoked s.17 leave
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked, or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances .
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to collect and return patients to the ward when s.17 leave is revoked
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked , was that they did not have the resources to allow them to do this , despite it being their legal responsibility so to do .
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked , placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, Sasha’s mother was given to believe that it would be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it.
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise the formal revocation of s.17 leave
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked, was that they did not have the resources to allow them to do this, despite it being their legal responsibility so to do.
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised , Sasha’s mother was given to believe that it would be , and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of shared awareness of powers and responsibilities when s.17 leave is revoked
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked , or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances.
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” Open source report
5 Apr 2019 Mrs Alice Doris Dixon · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 11 Failure to provide medical professional accompaniment or escort to the radiography suite View source Failure to involve an available support person during pre-scan form completion View source Failure of radiography-room layout and communication arrangements to enable recognition of breathing difficulties View source Lack of communication training and communication resources for language difficulties View source Failure to make notes in the radiography suite View source Failure to record known information about previous contrast exposure on the consent form View source Unavailability of clinically skilled assessment before the scan View source Failure to distinguish patient-provided information from computer-record information on consent forms View source Failure to provide assistance when obtaining consent from vulnerable patients View source Failure to identify the staff member completing and initialling part of a consent form View source Failure to document patient vulnerabilities for radiographer use View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mrs Alice Doris Dixon · 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
Alice Doris Dixon attended St Peter’s Hospital for investigation of anaemia and shortness of breath and suffered an anaphylactic shock during a CT scan involving injected contrast dye. She was admitted to intensive care, later treated palliatively, and died from the consequences of the shock. Concerns included inadequate support and communication during consent, incomplete and unclear consent documentation, lack of clinical assessment immediately before the scan, missing information about vulnerabilities, and difficulty observing or hearing her breathing difficulties during the scan.
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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide medical professional accompaniment or escort to the radiography suite
Wider context from the report “1. The evidence before the court suggested that Mrs Dixon was not accompanied or escorted by a medical professional to the radiography suite .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve an available support person during pre-scan form completion
Wider context from the report “2. Her daughter was not invited into the room when the pre-scan form was completed .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of radiography-room layout and communication arrangements to enable recognition of breathing difficulties
Wider context from the report “11. The way the room was set up it was difficult for the radiographer to realise that Mrs Dixon was having breathing difficulties during the scan as he was only able to see the top of her head and it was hard for him to hear over the sound of the scanner through the intercom in the scanner itself .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of communication training and communication resources for language difficulties
Wider context from the report “7. The radiographer who filled in the form had no training in communication or language difficulties and there were no other resources to aid communication and the questions were yes/no .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make notes in the radiography suite
Wider context from the report “8. No notes were made in the radiography suite .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record known information about previous contrast exposure on the consent form
Wider context from the report “6. Part of the consent form about previous contrast was left blank and although the RCA had the information before the scan it was not noted .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of clinically skilled assessment before the scan
Wider context from the report “9. Mrs Dixon was assessed before attending the radiography suite but there was no one with clinical skills to assess her prior to the scan itself and .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish patient-provided information from computer-record information on consent forms
Wider context from the report “4. The consent form was also supplemented with information from the computer records but it was not clear on the form or in evidence which information came from Mrs Dixon and which from records .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide assistance when obtaining consent from vulnerable patients
Wider context from the report “3. The consent form was filled in by the radiographer on asking questions of Mrs Dixon alone who was vulnerable, unwell, confused and hard of hearing in an unfamiliar environment without assistance .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the staff member completing and initialling part of a consent form
Wider context from the report “5. Part of the consent form was filled in and initialled by a person who cannot be identified by the Trust as to which member of staff it was .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document patient vulnerabilities for radiographer use
Wider context from the report “10. There was no note to assist the radiographer with any vulnerabilities Mrs Dixon had (including cranial hearing and understanding difficulties and issues that she was not able to lie flat )
” Open source report
3 Jan 2018 Margaret Jean Silver · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Failure of hospital discharge-summary procedures to provide accurate and consistent prescribed-medication information View source Failure of discharge-planning procedures to pass occupational therapists’ recommendations for necessary support and equipment to community carers View source Failure of hospital admission and discharge medication-recording procedures to identify non-receipt of potentially life-saving medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Margaret Jean Silver · 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
Margaret Jean Silver, an 85-year-old resident of a care home, developed pulmonary emboli after Rivaroxaban was discontinued following contradictory medication instructions in her hospital discharge summary. She later experienced reduced mobility, sustained a fractured femur in an assisted fall, developed a chest infection, and died in hospital. Concerns included contradictory discharge medication information, failure to identify that Rivaroxaban had been discontinued, and failures in communicating and implementing recommended discharge support and equipment.
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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital discharge-summary procedures to provide accurate and consistent prescribed-medication information
Wider context from the report “- Current procedures may result in inaccurate or contradictory information about prescribed medication being included in hospital discharge summaries .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of discharge-planning procedures to pass occupational therapists’ recommendations for necessary support and equipment to community carers
Wider context from the report “- The procedures in place for discharge planning may fail to ensure that occupational therapists’ recommendations regarding necessary support and equipment are not passed on to those caring for patients in the community .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital admission and discharge medication-recording procedures to identify non-receipt of potentially life-saving medication
Wider context from the report “- The procedures in place for recording a patient’s medication on admission to, and discharge from, hospital may fail to identify circumstances in which a patient is no longer in receipt of potentially life-saving medication .
” 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 Amend the discharge-letter template to consolidate medication information and instruct junior doctors to keep medication instructions in that section.
Verbatim wording from the response “The Trusts discharge letter template is to be amended to enhance safety associated with the generation and consequently improve end-user clarity regarding medications. All information pertaining to medications will be included in the same section on the discharge letter. An instruction note to be added to inform the Junior Doctors that all medication instructions should be confined to the medication section on the letter.” Source location 2018-0002-Response-by-Ashford-and-St-Peters-Hospitals-NHS-Trust
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 Add a discharge-summary section for therapists to provide community providers with instructions about equipment required after discharge.
Verbatim wording from the response “The ‘Red Bag’ process described above will improve the multidisciplinary communication between providers. Additionally there will be a section added to the discharge summary letter whereby Therapists can provide community providers with appropriate instructions regarding equipment required following discharge.” Source location 2018-0002-Response-by-Ashford-and-St-Peters-Hospitals-NHS-Trust
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 Pilot red bags and care passports with care providers, including updated information and earlier communication before and after hospital discharge.
Verbatim wording from the response “The Trust has commenced a pilot on the 12th February 2018 on new ways of working with nursing, residential and domiciliary care providers. Since March 2017 a multidisciplinary team of professionals from Ashford and St Peter’s NHS Foundation Trust and Adult Social Care have been working with a number of providers to identify better ways of working that will improve outcomes for individuals during and after their stay in hospital.” Source location 2018-0002-Response-by-Ashford-and-St-Peters-Hospitals-NHS-Trust
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 Introduce electronic prescribing to improve medicines communication, decision support, administration, supply and auditability.
Verbatim wording from the response “The Trust intends to introduce electronic prescribing in 2019. This system utilises electronic systems to facilitate and enhance the communication of a prescription or medicine order, aiding the choice, administration and supply of a medicine through knowledge and decision support and providing a robust audit trail for the entire medicines use process.” Source location 2018-0002-Response-by-Ashford-and-St-Peters-Hospitals-NHS-Trust
Open published response
1 Jun 2016 Rhi anne Anoushka Florence BARTON · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Failure to accurately record routine observations, fluid balance and gastrointestinal losses View source Failure to make specific obstetric care plans for pregnancy and labour after bariatric surgery View source Failure to provide timely obstetric consultant supervision after emergency admission View source Lack of specific clinical guidance on obstetric care after bariatric surgery View source Failure to act on markedly abnormal urine glucose findings View source Delays in undertaking appropriate investigations for unexplained abdominal pain View source Failure to consider surgical causes of abdominal symptoms after bariatric surgery View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rhi anne Anoushka Florence BARTON · 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
Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric surgery.
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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record routine observations, fluid balance and gastrointestinal losses
Wider context from the report “4. Evidence was presented of poor documentation of routine observations and an incomplete fluid balance chart . No accurate records were kept with regard to fluid intake and urine output . It was not possible to assess the amount, frequency and volume of the vomitus . There was no evidence of diarrhoea despite a diagnosis of gastroenteritis . A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding.
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make specific obstetric care plans for pregnancy and labour after bariatric surgery
Wider context from the report “5. The obstetric consultant made no specific plans with regard to the obstetric care that Rhi anne would receive during pregnancy and labour despite knowing that she had undergone bariatric surgery . I also heard evidence that bariatric surgery was becoming increasingly common but the Royal College of Obstetrics and Gynaecology had not specifically addressed this issue in their guidance to practicing clinicians.
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely obstetric consultant supervision after emergency admission
Wider context from the report “1. Rhi anne’s named obstetric consultant was not informed of her emergency admission . Although there was a consultant obstetrician on the ward on the 11th February there was no request for Rhi anne to be seen and in any event it was not common practice for patients to be seen by another consultant. As such there was no obstetric consultant supervision of Rhi anne from the time of admission until shortly before her surgery; approximately 43 hours after admission .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of specific clinical guidance on obstetric care after bariatric surgery
Wider context from the report “5. The obstetric consultant made no specific plans with regard to the obstetric care that Rhi anne would receive during pregnancy and labour despite knowing that she had undergone bariatric surgery. I also heard evidence that bariatric surgery was becoming increasingly common but the Royal College of Obstetrics and Gynaecology had not specifically addressed this issue in their guidance to practicing clinicians .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on markedly abnormal urine glucose findings
Wider context from the report “4. Evidence was presented of poor documentation of routine observations and an incomplete fluid balance chart. No accurate records were kept with regard to fluid intake and urine output. It was not possible to assess the amount, frequency and volume of the vomitus. There was no evidence of diarrhoea despite a diagnosis of gastroenteritis. A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in undertaking appropriate investigations for unexplained abdominal pain
Wider context from the report “3. I also heard evidence that whilst the rarity of an omental band may make it difficult to diagnose there was still a responsibility to exclude other causes of abdominal pain in the absence of an obstetric cause , by undertaking appropriate investigations in a timely fashion .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider surgical causes of abdominal symptoms after bariatric surgery
Wider context from the report “2. No consideration was given to excluding a surgical cause of Rhi anne’s symptoms despite the history of sudden onset of upper abdominal pain in the knowledge that she had had bariatric surgery . I heard evidence that bariatric surgery can, not infrequently, result in an omental/internal hernia causing small bowel obstruction but that it was not widely understood and should be given greater recognition nationally as more women are becoming pregnant following bariatric surgery.
” 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 Introduce the Vitalpac electronic system for capturing patient observations across most inpatient areas.
Verbatim wording from the response “An electronic system (Vitalpac) for capture of patient observations has been introduced into the Trust in the majority of inpatient areas. The Division have approached the developer of this system to see if modifications can be made to make it suitable for use in a maternity setting. This system can automatically calculate 'early warning scores' and issue alerts based on predetermined criteria.” Source location 2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
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 Introduce and disseminate a guideline covering care from booking through delivery for pregnant patients who previously underwent bariatric surgery.
Verbatim wording from the response “The Division (Womens Health and Paediatrics) have produced a Guideline For The Management Of Pregnant Women Who Have Previously Undergone Bariatric Surgery which details the care pathway for this group of patients from booking of the pregnancy through to delivery. The document was ratified by the Divisional Governance Group in December 2015 and widely publicised to all stakeholders within the Trust. A copy of this guideline is available on request.” Source location 2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
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 Introduce training and competency assessments for staff completing fluid-balance charts.
Verbatim wording from the response “In addition, a directed audit of documentation of fluid balance was undertaken in Joan Booker Ward in May 2015; this highlighted inconsistencies in chart completion with overall balance totals rarely calculated. As a result, a campaign to raise awareness of the importance of correctly documenting fluid balance was undertaken and new training and competency assessments were introduced for staff who complete fluid balance charts. A redesigned fluid balance chart has been developed to facilitate accurate and complete recording of input and output details. A repeat, in depth, audit of fluid balance documentation will take place later this year following introduction and embedding of the new chart.” Source location 2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
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 Conduct a repeat in-depth audit of fluid-balance documentation after the new chart is introduced and embedded.
Verbatim wording from the response “In addition, a directed audit of documentation of fluid balance was undertaken in Joan Booker Ward in May 2015; this highlighted inconsistencies in chart completion with overall balance totals rarely calculated. As a result, a campaign to raise awareness of the importance of correctly documenting fluid balance was undertaken and new training and competency assessments were introduced for staff who complete fluid balance charts. A redesigned fluid balance chart has been developed to facilitate accurate and complete recording of input and output details. A repeat, in depth, audit of fluid balance documentation will take place later this year following introduction and embedding of the new chart.” Source location 2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
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 Review and amend the bariatric-surgery pregnancy guideline when Royal College guidance is published.
Verbatim wording from the response “The guideline will be reviewed and amended as required when the Royal College of Obstetrics and Gynaecology publish thier own guidance.” Source location 2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
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 Run an awareness campaign emphasising accurate fluid-balance documentation on Joan Booker Ward.
Verbatim wording from the response “In addition, a directed audit of documentation of fluid balance was undertaken in Joan Booker Ward in May 2015; this highlighted inconsistencies in chart completion with overall balance totals rarely calculated. As a result, a campaign to raise awareness of the importance of correctly documenting fluid balance was undertaken and new training and competency assessments were introduced for staff who complete fluid balance charts. A redesigned fluid balance chart has been developed to facilitate accurate and complete recording of input and output details. A repeat, in depth, audit of fluid balance documentation will take place later this year following introduction and embedding of the new chart.” Source location 2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
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 a redesigned fluid-balance chart to support complete recording of patient input and output.
Verbatim wording from the response “In addition, a directed audit of documentation of fluid balance was undertaken in Joan Booker Ward in May 2015; this highlighted inconsistencies in chart completion with overall balance totals rarely calculated. As a result, a campaign to raise awareness of the importance of correctly documenting fluid balance was undertaken and new training and competency assessments were introduced for staff who complete fluid balance charts. A redesigned fluid balance chart has been developed to facilitate accurate and complete recording of input and output details. A repeat, in depth, audit of fluid balance documentation will take place later this year following introduction and embedding of the new chart.” Source location 2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
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 Implement daily consultant review of patients on Joan Booker Ward, with labour ward consultant cover when usual consultants are unavailable.
Verbatim wording from the response “We have actioned a change in Consultant working practices to facilitate timely review of patients on Joan Booker Ward. The default planning is that Consultants will review patients under their care every working day; where other commitments or absences preclude this, and at weekends, the labour ward Consultant will review the patients. This pattern of working has been in place since March 2015. I have included as Appendix 1, the details of this working pattern.” Source location 2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
Open published response
22 Feb 2016 Clifford Irwin Crofts · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Delays and restricted access in obtaining urgent CT scans View source Failure of the process for escalating care within and between disciplines View source Lack of accessible guidance on the process for arranging CT scans View source Lack of staff awareness and understanding of enterostomy care policies and guidance View source Insufficient numbers of doctors at all levels of seniority available at weekends View source Failure to follow care plans for patients who have undergone enterostomies View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Clifford Irwin Crofts · 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
Clifford Irwin Crofts, who had Parkinson’s disease and aspiration difficulties, was admitted to hospital and underwent insertion of a radiologically inserted gastrostomy tube on 19 September 2014. He experienced acute pain after feeding began, but there were delays in escalating his care, obtaining a CT scan and carrying out surgery; he subsequently developed respiratory difficulties and died on 10 October 2014. The substantive concerns included failure to follow the RIG care plan, difficulties escalating care, delays in obtaining urgent CT imaging, and weekend staffing levels.
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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and restricted access in obtaining urgent CT scans
Wider context from the report “(3) There were considerable difficulties obtaining a CT scan on Sunday, 21 September 2014. This was partly because it was not actioned at 16.00, when requested . After 17.00 on the weekend the request had to be made by a consultant to an outside provider Medica who read the scans when no-one is available at the hospital. It appears that junior doctors can now request CT scans and that a new arrangement is being put in place to obtain urgent CT scans in cases of suspected peritonitis. The SI report recommends that guidance relating to CT scanning on the trust intranet should be reviewed to clarify the process for arranging investigations and be made available as part of the induction process for junior doctors and on the ward areas, for other staff to access. I was informed this has not yet been actioned.
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the process for escalating care within and between disciplines
Wider context from the report “(2) There were considerable difficulties in escalating Mr Crofts’ care on 20 and 21 September 2014. The SI report recommends that the process by which care is escalated within and between disciplines needs to be reviewed and clarified to ensure that patients receive timely attention. Again, I am not satisfied on the evidence I have heard that this recommendation has been implemented .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of accessible guidance on the process for arranging CT scans
Wider context from the report “(3) There were considerable difficulties obtaining a CT scan on Sunday, 21 September 2014. This was partly because it was not actioned at 16.00, when requested. After 17.00 on the weekend the request had to be made by a consultant to an outside provider Medica who read the scans when no-one is available at the hospital. It appears that junior doctors can now request CT scans and that a new arrangement is being put in place to obtain urgent CT scans in cases of suspected peritonitis. The SI report recommends that guidance relating to CT scanning on the trust intranet should be reviewed to clarify the process for arranging investigations and be made available as part of the induction process for junior doctors and on the ward areas, for other staff to access . I was informed this has not yet been actioned .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness and understanding of enterostomy care policies and guidance
Wider context from the report “(1) The Trust’s care plan no 94 RIG was not followed. The SI report dated the 20 August 2015 (page 19) recommends that relevant staff members are aware of and understand the policies, guidance and supporting documentation which relate to the care of patients who have undergone enterostomies . I was informed this recommendation had not yet been put into effect .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient numbers of doctors at all levels of seniority available at weekends
Wider context from the report “(4)During the course of evidence it became clear that the delay in attempts to escalate Mr Crofts’ care over the weekend was due in large part to staffing levels. Whilst I heard that staffing levels at weekends have increased since 2014, it was not clear that the number of doctors at all levels of seniority available at weekends is sufficient to provide safe care to in patients at the hospital particularly at times when emergencies arise in A and E .
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow care plans for patients who have undergone enterostomies
Wider context from the report “(1) The Trust’s care plan no 94 RIG was not followed . The SI report dated the 20 August 2015 (page 19) recommends that relevant staff members are aware of and understand the policies, guidance and supporting documentation which relate to the care of patients who have undergone enterostomies. I was informed this recommendation had not yet been put into effect.
” 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 Pilot an SBAR-based inpatient referral template on the labour ward, specifying response seniority, review timescales and escalation steps.
Verbatim wording from the response “• Difficulties with inter-specialty referral of inpatients have been identified in several SI reports and a pilot scheme has been developed for use on labour ward which utilises a referral template based on SBAR principles. SBAR is a formal communication tool recommended by the NHS Institute for Innovation and Improvement which consists of standardised prompt questions within four sections (Situation, Background, Assessment and Recommendation), to ensure that staff are sharing concise and focused information. It allows staff to communicate assertively and effectively.” Source location Clifford-CROFTS-Response
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 Provide an online nutritional-care training module covering feeding enterostomies and signpost junior doctors during induction.
Verbatim wording from the response “• A module has been produced for our on line training system for staff (Training Tracker) which covers many aspects of nutritional care including the use and complication of feeding enterostomies. Our junior doctors are signposted to this system and its contents during their induction program prior to commencing clinical duties at the Trust.” Source location Clifford-CROFTS-Response
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 Schedule feeding enterostomy procedures on weekdays to enable Nutritional Support Specialist Nurses to provide directed ward training.
Verbatim wording from the response “• These procedures are not urgent and are no longer undertaken on Fridays (or at weekends). This enables the Nutritional Support Specialist Nurses to provide specific and directed training to ward areas each time one of these patients is present.” Source location Clifford-CROFTS-Response
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 Define minimum safe medical staffing levels for each clinical area and doctor grade through a Medical Director-led workstream.
Verbatim wording from the response “• In contrast to nursing practice, there is no guidance as to what constitutes ‘safe staffing’ for doctors. This is an issue we are trying to address at Ashford and St Peter’s and the Medical Director is leading a work-stream which is attempting to define, for each clinical area and each grade of doctor, the safe minimal level of medical staffing.” Source location Clifford-CROFTS-Response
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 Make enterostomy care plans available on the Trust intranet and in wards admitting patients with enterostomies.
Verbatim wording from the response “• The Care plans detailing the use of enterostomies and their complications are available on the Trust intranet via any workstation in the organisation and will be present in any ward where such a patient is an inpatient.” Source location Clifford-CROFTS-Response
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 Provide an additional doctor on the emergency medical take from 16:00 to 23:00 every day through adjusted junior-doctor rotas.
Verbatim wording from the response “• We have recently adjusted the medical junior doctor rotas such that there is an extra doctor on the emergency medical take from 16:00 to 23:00 every day.” Source location Clifford-CROFTS-Response
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 Commence the RIG care plan in radiology and send it with patients to the ward, including device-management and complication guidance.
Verbatim wording from the response “• The RIG care plan is commenced in radiology when the device is inserted and accompanies the patient to the ward area. The care plan has full details of the management of these devices and the complications which may result from their insertion or use.” Source location Clifford-CROFTS-Response
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 Remove routine Medica-radiologist discussion or direct consultant involvement for specified urgent CT pathways, while retaining radiologist discussion for other out-of-hours scans.
Verbatim wording from the response “• Scans for patients on the following pathways no longer require a discussion with the Medica radiologist” Source location Clifford-CROFTS-Response
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 Provide revised out-of-hours CT-requesting guidance in full and abbreviated forms on the intranet and through junior-doctor induction.
Verbatim wording from the response “• There is a revised guidance document available for doctors who request CT scanning out of hours (Mon – Fri 20:00 to 08:00 and Sat, Sun & Bank holidays 17:00 to 09:00).” Source location Clifford-CROFTS-Response
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 Current contractual restrictions limit the ability to roster doctors for elective work during premium time, constraining implementation of identified safe staffing levels.
Verbatim wording from the response “It is likely the implementation of identified safe staffing levels for doctors will require the introduction of the new contracts for both junior doctors and consultants as at present there are significant restrictions on our ability to roster doctors to perform elective work within ‘premium time’ (19:00 to 07:00 weekdays and any time at weekends).” Source location Clifford-CROFTS-Response
Open published response
5 Feb 2014 Keith Ronald Martin · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 9 Delays in receiving ECG and blood test results View source Delays in providing standard pharmacological treatment for chest pain or myocardial infarction View source Failure to recognise the significance of symptoms at triage View source Delays in undertaking ECG and blood tests after initial triage View source Lack of clarity in the A&E chest pain management protocol View source Delays in initial A&E assessment of patients with presenting symptoms View source Delays in senior clinical review View source Lack of effective clinical documentation View source Failure to promptly recognise and act on a rise in troponin View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Keith Ronald Martin · 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
Keith Ronald Martin attended A&E with chest pain and left-arm tingling, but there were delays in triage, investigations, treatment and senior review. He later deteriorated with a myocardial infarction, was transferred for emergency treatment, and died after the infarction was described as incompatible with life. The concerns included failure to appreciate and act promptly on his symptoms and raised troponin, unclear chest-pain management protocols, and inadequate documentation.
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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in receiving ECG and blood test results
Wider context from the report “4. The length of time taken to receive the results of these tests
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in providing standard pharmacological treatment for chest pain or myocardial infarction
Wider context from the report “7. The length of time taken to provide standard pharmacological treatment for chest pain or myocardial infarction
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the significance of symptoms at triage
Wider context from the report “2. The significance of Mr Martin’s symptoms were not appreciated at triage
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in undertaking ECG and blood tests after initial triage
Wider context from the report “3. The length of time taken to undertake an ECG and blood tests after initial triage
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in the A&E chest pain management protocol
Wider context from the report “8. A lack of clarity as to the protocol for the management of chest pain in A&E
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in initial A&E assessment of patients with presenting symptoms
Wider context from the report “1. The length of time taken to initially assess Mr Martin in A&E, given his presenting symptoms
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in senior clinical review
Wider context from the report “6. The length of time taken for Mr Martin to be reviewed by a senior member of staff
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective clinical documentation
Wider context from the report “9. An overall lack of effective documentation
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly recognise and act on a rise in troponin
Wider context from the report “5. The significance of the rise in troponin was not appreciated or acted upon promptly
” Open source report
31 Jan 2014 William George KENT · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Lack of clarity on the use of Haz-Tab granules in clinical spillages View source Lack of awareness of Haz-Tab granules’ potentially harmful side-effects for urine spillages View source Under-emphasis of hazardous consequences from noxious gas release when Haz-Tab granules contact urine View source Limited teaching of cleaning products’ side-effects during staff induction and mandatory infection control updates View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
William George KENT · 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 George KENT was admitted to hospital after a fall and later developed acute respiratory distress after Haz-Tab granules were used on urine near his bed. He was transferred for further treatment but died after chlorine inhalation was identified as a significant contributing trigger. Concerns included insufficient awareness and training about the hazards and appropriate use of Haz-Tab granules, including the release of noxious gases when they contact urine.
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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity on the use of Haz-Tab granules in clinical spillages
Wider context from the report “3. Lack of clarity on how Haz-Tab granules should be used in clinical spillages
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of Haz-Tab granules’ potentially harmful side-effects for urine spillages
Wider context from the report “1. Lack of awareness of the potentially harmful side-effects of Haz-Tab granules for urine spillages
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Under-emphasis of hazardous consequences from noxious gas release when Haz-Tab granules contact urine
Wider context from the report “4. An under-emphasis of the potential hazardous consequences from the release of noxious gases when Haz-Tab granules are in contact with urine (with or without contamination of blood)
” 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 Ashford and St Peter'S Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited teaching of cleaning products’ side-effects during staff induction and mandatory infection control updates
Wider context from the report “2. Limited time given over to the teaching of the side-effects of cleaning products such as Haz-Tab granules at the induction of new staff and at yearly mandatory infection control updates
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations