Concerns raised 2 Failure to account for patients’ mental health needs in falls risk assessments and mitigations View source Inadequate specialist mental health provision to support hospital staff caring for patients with mental health needs View source
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
Carolyne Senior · 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
Carolyne Senior died at Barnsley Hospital on 20 January 2019 after three falls while in the hospital’s care, resulting in fractures to both necks of femur. The report raised concerns that her mental health needs were not sufficiently considered in falls risk assessments and that specialist mental health support for hospital staff was inadequate.
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 Barnsley Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for patients’ mental health needs in falls risk assessments and mitigations
Wider context from the report “Evidence was given that Carolyne’s mental health issues could have inhibited her insight and ability to follow advice around falls prevention. The SI report author accepted in evidence that the question of whether hospital staff had sufficient access to advice to support them in caring for patients with mental health needs had not been addressed in that review.
Nursing evidence was to the effect that advice and guidance was limited. In particular that mental health staff could take a very long time to attend a ward when asked but, more generally, that mental health input was insufficient to support hospital staff in caring for such patients and was known to be provided to a better standard in other hospitals.
I was concerned that staff in Barnsley hospital did not take sufficient account of Carolyne’s mental health needs in formulating falls risk assessments and mitigations . I was concerned that there may be inadequate specialist provision to support staff in caring for patients with mental health needs such that these patients, some of whom may be challenging to care for, would therefore be placed at greater risk of falls than would be the case if risk assessments were formulated with their specific needs in mind.
” 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 Barnsley Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate specialist mental health provision to support hospital staff caring for patients with mental health needs
Wider context from the report “Evidence was given that Carolyne’s mental health issues could have inhibited her insight and ability to follow advice around falls prevention. The SI report author accepted in evidence that the question of whether hospital staff had sufficient access to advice to support them in caring for patients with mental health needs had not been addressed in that review .
Nursing evidence was to the effect that advice and guidance was limited . In particular that mental health staff could take a very long time to attend a ward when asked but, more generally, that mental health input was insufficient to support hospital staff in caring for such patients and was known to be provided to a better standard in other hospitals.
I was concerned that staff in Barnsley hospital did not take sufficient account of Carolyne’s mental health needs in formulating falls risk assessments and mitigations. I was concerned that there may be inadequate specialist provision to support staff in caring for patients with mental health needs such that these patients, some of whom may be challenging to care for, would therefore be placed at greater risk of falls than would be the case if risk assessments were formulated with their specific needs in mind.
” Open source report
Concerns raised 11 Delays and lack of clarity in prescribing deterioration monitoring View source Delays in Heparin-level testing and result availability View source Lack of clarity in recording whether Alteplase was followed by an infusion View source Unsafe use of unfractionated Heparin View source Clerking of acute patients by a medical student View source Failure to consider full-leg scanning for suspected lower-leg DVT View source Inappropriate placement of Emergency Department patients in AMU View source Poor safety-netting after attendance and scanning View source Poor recording of medication delivery View source Inconsistent practice regarding lower-leg scanning for deep vein thrombosis View source Delays in medical assessment of patients with classical DVT/PE symptoms View source See 8 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
Captain James Michael Bedford · 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
Captain James Michael Bedford, a senior long-haul airline pilot, developed a left-leg deep vein thrombosis and later collapsed after a flight from China. He suffered a pulmonary embolus and cerebral events, followed by an acute cerebral haemorrhage after treatment with heparin, and died on 30 June 2015. Concerns included differing hospital practices regarding lower-leg scanning for DVT and whether a full-leg scan at his first attendance might have provided an opportunity for treatment.
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 Barnsley Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and lack of clarity in prescribing deterioration monitoring
Wider context from the report “3. Whilst it is accepted that Emergency Departments are often busy, and sometimes exceptionally so, there was criticism at the inquest of the priority given to Captain Bedforth on his second admission when he was displaying classical symptoms of a DVT/PE. It appears that he was not medically assessed for at least two and a half hours after admission by ambulance. Deterioration was not prescribed until three hours post-admission and there was no evidence as to exactly when it was given (although likely shortly thereafter).
” 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 Barnsley Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in Heparin-level testing and result availability
Wider context from the report “5. There was no criticism of the use of 50mg Alteplase but there was a lack of clarity as to whether this was followed by an infusion. A further expert witness (a haematologist) criticised the subsequent use of unfractionated Heparin and a test of Heparin level seems to have taken a long time from sampling to delivery to the laboratory and later result . The evidence was strongly suggestive of over-anticoagulation by Heparin.
” 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 Barnsley Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in recording whether Alteplase was followed by an infusion
Wider context from the report “5. There was no criticism of the use of 50mg Alteplase but there was a lack of clarity as to whether this was followed by an infusion . A further expert witness (a haematologist) criticised the subsequent use of unfractionated Heparin and a test of Heparin level seems to have taken a long time from sampling to delivery to the laboratory and later result. The evidence was strongly suggestive of over-anticoagulation by Heparin.
” 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 Barnsley Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe use of unfractionated Heparin
Wider context from the report “5. There was no criticism of the use of 50mg Alteplase but there was a lack of clarity as to whether this was followed by an infusion. A further expert witness (a haematologist) criticised the subsequent use of unfractionated Heparin and a test of Heparin level seems to have taken a long time from sampling to delivery to the laboratory and later result. The evidence was strongly suggestive of over-anticoagulation by Heparin .
” 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 Barnsley Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Clerking of acute patients by a medical student
Wider context from the report “4. An expert witness (an ED physician) was critical of the placement in AMU and clerking in by a medical student although it is not suggested this of itself made a difference as to survival.
” 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 Barnsley Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider full-leg scanning for suspected lower-leg DVT
Wider context from the report “1. The inquest heard that the scanning practice followed after the first attendance was in accordance with NICE guidelines (indeed possibly a little in excess of the guidance) which did not include scanning of the lower leg . This was said to be on the basis that not all lower leg DVTs will be visible. Yet it became apparent that that there is mixed practice on this point, some hospitals clearly consider that lower leg scanning is worthwhile .
Hindsight strongly suggested that Captain Bedforth was developing clots in the left lower leg at the time of the first visit. The inquest found that a full leg scan might have provided the hospital with an opportunity to treat Captain Bedforth although it was accepted that no-one could be certain of this.
” 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 Barnsley Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate placement of Emergency Department patients in AMU
Wider context from the report “4. An expert witness (an ED physician) was critical of the placement in AMU and clerking in by a medical student although it is not suggested this of itself made a difference as to survival.
” 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 Barnsley Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor safety-netting after attendance and scanning
Wider context from the report “2. The evidence of 'safety-netting' after the first attendance (and/or subsequent attendance for scans) was poor and of considerable concern . As made clear in my written findings this was possibly of relevant as to Captain Bedforth's subsequent decision on seeking medical attention in or upon return from China.
” 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 Barnsley Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor recording of medication delivery
Wider context from the report “6. A number of issues were raised as to note-keeping or clarity of note-keeping, most particularly as regards delivery of medications .
” 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 Barnsley Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent practice regarding lower-leg scanning for deep vein thrombosis
Wider context from the report “The inquest heard that the scanning practice followed after the first attendance was in accordance with NICE guidelines (indeed possibly a little in excess of the guidance) which did not include scanning of the lower leg . This was said to be on the basis that not all lower leg DVTs will be visible. Yet it became apparent that there is mixed practice on this point, some hospitals clearly consider that lower leg scanning is worthwhile .
Hindsight strongly suggested that Captain Bedford was developing clots in the left lower leg at the time of the first visit. The inquest found that a full leg scan might have provided the hospital with an opportunity to treat Captain Bedford although it was accepted that no-one could be certain of this.
” 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 Barnsley Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in medical assessment of patients with classical DVT/PE symptoms
Wider context from the report “3. Whilst it is accepted that Emergency Departments are often busy, and sometimes exceptionally so, there was criticism at the inquest of the priority given to Captain Bedforth on his second admission when he was displaying classical symptoms of a DVT/PE. It appears that he was not medically assessed for at least two and a half hours after admission by ambulance . Deterioration was not prescribed until three hours post-admission and there was no evidence as to exactly when it was given (although likely shortly thereafter).
” 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 Invest in the VitalPac electronic observation system to improve recognition and response for deteriorating patients.
Verbatim wording from the response “4. We have and continue to ensure there are sound processes in all clinical areas regarding prompt escalation of unwell patients. This is covered on the induction programme for all medical students who are very familiar with the need to escalate if they see someone who is acutely unwell. We have also recently introduced an Acute Response Team of Advanced Nurse Practitioners who rapidly attend to support wards with patients who deteriorate. We have also invested in the VitalPac electronic observation system that has been demonstrated in other Trusts to improve the recognition and response for sick patients.” Source location 2016-0368-Barnsley-Hospital-NHS-Trust
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 Alter the thrombolysis pulmonary embolism guideline to prompt checking prior heparin administration and careful APTT monitoring.
Verbatim wording from the response “5. The Trust has altered the Thrombolysis PE guideline – amongst the changes we have addressed the concerns about checking whether heparin had been administered previously and to carefully check and monitor the APTT ratio. A copy of the revised guidance is attached for your information.” Source location 2016-0368-Barnsley-Hospital-NHS-Trust
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 Audit compliance with recording the provision of patient information sheets.
Verbatim wording from the response “2. There is a Patient Information Sheet for patients who have attended hospital for investigation for deep vein thrombosis or pulmonary embolism. (Attached) This sheet is handed to all such patients at discharge, along with verbal advice provided by our specialist nurses. The Thrombosis nurses now record in their notes that an information sheet has been given to the patient. This will be audited to assess compliance.” Source location 2016-0368-Barnsley-Hospital-NHS-Trust
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 consultant-led senior assessment in the START emergency assessment hub during its operating hours.
Verbatim wording from the response “3. In the Emergency Department (ED) there is now a consultant in the new assessment hub area, which should speed up the diagnosis and management of someone presenting in this way. The Short-Term Assessment of Risk and Treatability Hub (START) runs between the hours of 09:00 and 16:00 hours and is consultant led. The START consultant will provide a senior ‘front of house’ service to assist with the initial assessment and ensure the appropriate diagnostic testing is undertaken at the earliest opportunity. The Consultant will work alongside the assessment hub staff in ensuring a safe and rapid assessment process. The consultant predominantly receives patients arriving by ambulance, however patients that also ‘self present’ can be seen on START, if they are unwell, have an elevated NEWS score or require treatment within one hour.” Source location 2016-0368-Barnsley-Hospital-NHS-Trust
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 Record in thrombosis nurses’ notes when patients receive the DVT or pulmonary embolism information sheet.
Verbatim wording from the response “2. There is a Patient Information Sheet for patients who have attended hospital for investigation for deep vein thrombosis or pulmonary embolism. (Attached) This sheet is handed to all such patients at discharge, along with verbal advice provided by our specialist nurses. The Thrombosis nurses now record in their notes that an information sheet has been given to the patient. This will be audited to assess compliance.” Source location 2016-0368-Barnsley-Hospital-NHS-Trust
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 Introduce an Acute Response Team of Advanced Nurse Practitioners to rapidly support wards when patients deteriorate.
Verbatim wording from the response “4. We have and continue to ensure there are sound processes in all clinical areas regarding prompt escalation of unwell patients. This is covered on the induction programme for all medical students who are very familiar with the need to escalate if they see someone who is acutely unwell. We have also recently introduced an Acute Response Team of Advanced Nurse Practitioners who rapidly attend to support wards with patients who deteriorate. We have also invested in the VitalPac electronic observation system that has been demonstrated in other Trusts to improve the recognition and response for sick patients.” Source location 2016-0368-Barnsley-Hospital-NHS-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 The hospital will not change distal DVT ultrasound processes because additional scans may not detect all clots and empiric anticoagulation creates risks.
Verbatim wording from the response “1. The current NICE guidance for Venous Thromboembolism advises proximal leg USS investigation for those patients who are high risk based on Wells scoring and those who are low risk with a positive D-dimer. If negative, the patient should undergo a second proximal leg USS in 6-8 days time to exclude proximal propagation of a clot from a distal DVT. The rationale behind the NICE guidance is evidence-based following multiple studies.” Source location 2016-0368-Barnsley-Hospital-NHS-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 The apparent 2-hour-37-minute APTT delay was actually 1 hour 20 minutes because the form was pre-prepared.
Verbatim wording from the response ““The sample for APTT testing was timed as being collected from ICU at 19.58hrs, but the sample was not taken until 21.15hrs and not received by pathology until 21.24. The results were reported to ICU at 22.35hrs, so an apparent delay of 2 hours and 37 minutes seemed to have occurred.” Source location 2016-0368-Barnsley-Hospital-NHS-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 Close medical supervision after discharge following a negative scan is already triggered by the Thrombosis nurse and consultant referral.
Verbatim wording from the response “In relation to your concern regarding the discharge of a patient like Captain Bedforth following a negative scan and whether he requires close supervision by a doctor, this practice is already in place and is triggered by the Thrombosis nurse. The process is that if the Thrombosis Service Sister has concerns regarding a patient they are referred to the consultant for review in the DVT clinic. The Thrombosis Sister has stated that Captain Bedforth’s case is the first case of its kind she has been aware of in the last 15 years. We will be interested to see whether national guidance changes following your letter and would adapt our local guidelines accordingly, if so.” Source location 2016-0368-Barnsley-Hospital-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations