4 Apr 2025 Jacqueline GREEN · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 5 Failure to ensure accurate patient weights are entered before paracetamol prescribing View source Failure to address or adopt safeguards against unintentional paracetamol overdose in low-bodyweight adult inpatients View source Lack of practical arrangements to ensure patients are weighed on admission and the information documented View source Absence of electronic alerts for weight accuracy and liver-toxicity risk in oral paracetamol prescribing View source Absence of medication-administration alerts for adults at risk of unintentional paracetamol overdose View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacqueline GREEN · 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
Jacqueline GREEN was admitted to Bedford Hospital after a fall and was found to be very weak, frail, cachectic and dehydrated. She received paracetamol at a dose intended for patients weighing over 50 kg despite weighing 33.6 kg, subsequently developed paracetamol-induced liver injury and died from liver failure. The concerns included inadequate safeguards for prescribing paracetamol to low-weight adults, unexplained variation in the administration of doses, and incomplete implementation of relevant safety measures.
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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate patient weights are entered before paracetamol prescribing
Wider context from the report “3. Despite the PSII report referencing the 2022 HSSIB report and recommending that this should be shared with staff, relevant Safety Observations made in the HSSIB Report appear to have been insufficiently addressed:
(a) Although Bedford Hospitals NHS Trust are now using the Nevercentre electronic record system which, since 28th February 2024, has included the height and weight of patients and prevents a prescribing doctor from prescribing without a patient’s weight having first been entered, staff are still able to enter a estimated weight and there do not appear to be any alerts on this system to advise of the need for weight accuracy in the prescription of oral paracetamol and consideration of the risk of liver toxicity in those weighing under 50 kg (as advised in Safety Observation 02/2022/151);
(b) Whilst the PSII report states as an Action that “Patients should be weighed on admission and the information documented”, other than the provision of a ‘pat slide’, no other practical actions are planned for actually achieving this outcome, particularly in respect of those adults at risk of an unintentional paracetamol overdose, such as an alert aimed at those administering medication as well as those prescribing it (as advised in Safety Observation 02/2022/151).
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address or adopt safeguards against unintentional paracetamol overdose in low-bodyweight adult inpatients
Wider context from the report “1. Despite the fact that the HSSIB made Safety Observations to mitigate the risks of unintentional paracetamol overdose in adult inpatients with low bodyweight in their National Report dated 24.02.2022 (https://www.hssib.org.uk/patient-safety-investigations/unintentional-overdose-of-paracetamol-in-adults-with-low-bodyweight/) none of these had been addressed/adopted at Bedford Hospital by the time of the Deceased’s admission on 29 August 2023 which meant that, despite weighing only 33.6kg, the deceased was prescribed a daily dose of 1,000 mg x 4 which was only suitable for a patient weighing in excess of 50kg.
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of practical arrangements to ensure patients are weighed on admission and the information documented
Wider context from the report “3. Despite the PSII report referencing the 2022 HSSIB report and recommending that this should be shared with staff, relevant Safety Observations made in the HSSIB Report appear to have been insufficiently addressed:
(a) Although Bedford Hospitals NHS Trust are now using the Nevercentre electronic record system which, since 28th February 2024, has included the height and weight of patients and prevents a prescribing doctor from prescribing without a patient’s weight having first been entered, staff are still able to enter a estimated weight and there do not appear to be any alerts on this system to advise of the need for weight accuracy in the prescription of oral paracetamol and consideration of the risk of liver toxicity in those weighing under 50 kg (as advised in Safety Observation 02/2022/151);
(b) Whilst the PSII report states as an Action that “Patients should be weighed on admission and the information documented”, other than the provision of a ‘pat slide’, no other practical actions are planned for actually achieving this outcome , particularly in respect of those adults at risk of an unintentional paracetamol overdose, such as an alert aimed at those administering medication as well as those prescribing it (as advised in Safety Observation 02/2022/151).
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of electronic alerts for weight accuracy and liver-toxicity risk in oral paracetamol prescribing
Wider context from the report “3. Despite the PSII report referencing the 2022 HSSIB report and recommending that this should be shared with staff, relevant Safety Observations made in the HSSIB Report appear to have been insufficiently addressed:
(a) Although Bedford Hospitals NHS Trust are now using the Nevercentre electronic record system which, since 28th February 2024, has included the height and weight of patients and prevents a prescribing doctor from prescribing without a patient’s weight having first been entered, staff are still able to enter a estimated weight and there do not appear to be any alerts on this system to advise of the need for weight accuracy in the prescription of oral paracetamol and consideration of the risk of liver toxicity in those weighing under 50 kg (as advised in Safety Observation 02/2022/151);
(b) Whilst the PSII report states as an Action that “Patients should be weighed on admission and the information documented”, other than the provision of a ‘pat slide’, no other practical actions are planned for actually achieving this outcome, particularly in respect of those adults at risk of an unintentional paracetamol overdose, such as an alert aimed at those administering medication as well as those prescribing it (as advised in Safety Observation 02/2022/151).
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of medication-administration alerts for adults at risk of unintentional paracetamol overdose
Wider context from the report “3. Despite the PSII report referencing the 2022 HSSIB report and recommending that this should be shared with staff, relevant Safety Observations made in the HSSIB Report appear to have been insufficiently addressed:
(a) Although Bedford Hospitals NHS Trust are now using the Nevercentre electronic record system which, since 28th February 2024, has included the height and weight of patients and prevents a prescribing doctor from prescribing without a patient’s weight having first been entered, staff are still able to enter a estimated weight and there do not appear to be any alerts on this system to advise of the need for weight accuracy in the prescription of oral paracetamol and consideration of the risk of liver toxicity in those weighing under 50 kg (as advised in Safety Observation 02/2022/151);
(b) Whilst the PSII report states as an Action that “Patients should be weighed on admission and the information documented”, other than the provision of a ‘pat slide’, no other practical actions are planned for actually achieving this outcome, particularly in respect of those adults at risk of an unintentional paracetamol overdose, such as an alert aimed at those administering medication as well as those prescribing it (as advised in Safety Observation 02/2022/151).
” 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 Develop and trial a cross-site live dashboard showing ward compliance with timely patient weighing.
Verbatim wording from the response “What the Trust are trialling is a live dashboard that shows the patient weight compliance for all wards across both hospital sites. Once completed it will be directed towards ward managers and matrons, who at any time will be able to see how many patients have been weighed on a particular ward.” Source location Response from Bedford Hospitals NHS Foundation 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 EPMA prescribing prompts requiring accurate weight recording and appropriate paracetamol dosing, including liver-toxicity warnings below 50 kilograms.
Verbatim wording from the response “There is now a prompt when prescribing paracetamol (all routes) on EPMA that reminds prescribers of the need to ensure there is an accurate weight recorded and that the dose is appropriate.” Source location Response from Bedford Hospitals NHS Foundation 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 Produce and launch a Nervecentre paracetamol prescribing guide.
Verbatim wording from the response “A Nervecentre paracetamol prescribing guide has been produced and been launched in to support safe prescribing of paracetamol.” Source location Response from Bedford Hospitals NHS Foundation Trust
Open published response
×
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 Trust cannot currently provide more costly weighing equipment because it lacks the available financial resources.
Verbatim wording from the response “4. Additional actions related to monitoring weight to reduce risk” Source location Response from Bedford Hospitals NHS Foundation Trust
Open published response
25 Aug 2022 Yuksel Bedri ISMAIL · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 4 Failure to assess the needs of at-risk patients in transfer arrangements View source Failure to train staff in the application of the Mental Capacity Act during patient transfers View source Failure to prevent at-risk patients from leaving the emergency department while awaiting mental health assessment View source Failure to consult PLS staff about escort and transfer arrangements View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Yuksel Bedri ISMAIL · 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
Yuksel Bedri ISMAIL, aged 23, absconded from hospital while awaiting a mental health assessment and was struck by an HGV on the M1 motorway on 28 November 2021, suffering fatal injuries. The concerns included hospital transfer arrangements for patients at risk of absconding and insufficient staff training and understanding regarding the Mental Capacity Act and preventing high-risk patients from leaving the emergency department.
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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess the needs of at-risk patients in transfer arrangements
Wider context from the report “1. The Court was told that SI investigation had not been completed by the Trust in this case; however, the PEARL Meeting on 3 December 2021 acknowledged that "the current transfer policy needs reviewing ...the transfer policy implemented around the mental health patients should be prioritised as there are risks involving patients and staff, all depending on the assessment of the patient ". Despite this and ELFT's own SI Report (disclosed to the Trust before the PIRH held on 26 May 2022) having highlighted the need for PLS staff to be involved in any decision regarding patients waiting for MHA assessment, or who may need to be conveyed to another area within the hospital site as 'such patients are high risk and often unpredictable', by the start of the Inquest held on 24 August 2022, there was no evidence of Bedford Hospitals NHS Trust's acceptance of the recommendations made.
Whilst at lunchtime on the day of the Inquest itself, the Court was provided with a draft of a new Transfer Policy, this Policy still did not appear to have addressed the main issue:
- Whilst it includes "Confused, disorientated, self-harming, suicidal or displaying erratic or aggressive behaviours" and "patients at risk of absconding" in the list of 'At risk' patients in Section 3, the needs of such patients are still not addressed in the Assessment Tool (Appendix 4) nor is the need for consultation with the PLS staff about any of the escort/transfer arrangements.
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to train staff in the application of the Mental Capacity Act during patient transfers
Wider context from the report “2. Although ELFT's SI Report (disclosed to the Trust before the PIRH held on 26 May 2022) had highlighted that "There is a need for staff involved in transferring patients, including security staff, to have training in the exercise of the Mental Capacity Act to ensure that patients who are assessed as lacking capacity with identified risks to self are unable to leave the emergency department" and recommended that "training be provided to acute Trust colleagues on the application of the Mental Capacity Act, its use to restrain/prevent somebody leaving the department if they are deemed to lack capacity and there are concerns regarding their risk should they leave, and where the person has capacity but remains a risk to themselves", there was no evidence before the Inquest of Bedford Hospitals NHS Trust's acknowledgment or consideration of this .
Instead:
- The Court heard from several Trust witnesses including a ED Sister, that they considered they had no powers to detain someone within the ED ;
- The statement provided to the Inquest by the ED Lead, ████████ (provided to the Court along with notice that he would NOT be available to attend the Inquest even though at the PIRH the Court had made it clear that the witness providing evidence of relevant Trust Policy would need to attend the Inquest) appeared confused about the powers available :
Para 12 "Physical restraint is permitted in circumstances where the patient is confirmed to lack mental capacity and the
restraint is necessary to preserve life or health and is proportionate to risk"
Para 17 "Even if a single security officer had assisted with the transfer, they would be unable to physically restrain as the
restraint policy specifies a minimum of two security officers are required for this and Mr Ismail was not subject to lawful DOLS at that point";
- PLS Staff stated that they have known of other patients leaving the ED whilst awaiting a MHA assessment
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent at-risk patients from leaving the emergency department while awaiting mental health assessment
Wider context from the report “2. Although ELFT's SI Report (disclosed to the Trust before the PIRH held on 26 May 2022) had highlighted that "There is a need for staff involved in transferring patients, including security staff, to have training in the exercise of the Mental Capacity Act to ensure that patients who are assessed as lacking capacity with identified risks to self are unable to leave the emergency department " and recommended that "training be provided to acute Trust colleagues on the application of the Mental Capacity Act, its use to restrain/prevent somebody leaving the department if they are deemed to lack capacity and there are concerns regarding their risk should they leave, and where the person has capacity but remains a risk to themselves", there was no evidence before the Inquest of Bedford Hospitals NHS Trust's acknowledgment or consideration of this.
Instead:
- The Court heard from several Trust witnesses including a ED Sister, that they considered they had no powers to detain someone within the ED ;
- The statement provided to the Inquest by the ED Lead, ████████ (provided to the Court along with notice that he would NOT be available to attend the Inquest even though at the PIRH the Court had made it clear that the witness providing evidence of relevant Trust Policy would need to attend the Inquest) appeared confused about the powers available:
Para 12 "Physical restraint is permitted in circumstances where the patient is confirmed to lack mental capacity and the
restraint is necessary to preserve life or health and is proportionate to risk"
Para 17 "Even if a single security officer had assisted with the transfer, they would be unable to physically restrain as the
restraint policy specifies a minimum of two security officers are required for this and Mr Ismail was not subject to lawful DOLS at that point";
- PLS Staff stated that they have known of other patients leaving the ED whilst awaiting a MHA assessment
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consult PLS staff about escort and transfer arrangements
Wider context from the report “1. The Court was told that SI investigation had not been completed by the Trust in this case; however, the PEARL Meeting on 3 December 2021 acknowledged that "the current transfer policy needs reviewing...the transfer policy implemented around the mental health patients should be prioritised as there are risks involving patients and staff, all depending on the assessment of the patient". Despite this and ELFT's own SI Report (disclosed to the Trust before the PIRH held on 26 May 2022) having highlighted the need for PLS staff to be involved in any decision regarding patients waiting for MHA assessment, or who may need to be conveyed to another area within the hospital site as 'such patients are high risk and often unpredictable', by the start of the Inquest held on 24 August 2022, there was no evidence of Bedford Hospitals NHS Trust's acceptance of the recommendations made.
Whilst at lunchtime on the day of the Inquest itself, the Court was provided with a draft of a new Transfer Policy, this Policy still did not appear to have addressed the main issue:
- Whilst it includes "Confused, disorientated, self-harming, suicidal or displaying erratic or aggressive behaviours" and "patients at risk of absconding" in the list of 'At risk' patients in Section 3, the needs of such patients are still not addressed in the Assessment Tool (Appendix 4) nor is the need for consultation with the PLS staff about any of the escort/transfer arrangements .
” 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 Update Mental Capacity Act and restraint training for Emergency Department junior doctors.
Verbatim wording from the response “In response to concerns regarding application of the Mental Capacity Act and restraint training, the Emergency Department together with the Trust’s Safeguarding Team have worked with colleagues at ELFT to review the current provision for staff in the Emergency Department. This has led to amendments which include updates to MCA and restraint training for junior doctors in the Emergency Department and monthly shared learning forums with the PLS and the acute medicine team where particularly complex cases are also reviewed.” Source location Response from Bedfordshire Hospital NHS Foundation 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 Emergency Department staff provision for Mental Capacity Act and restraint training with ELFT colleagues.
Verbatim wording from the response “In response to concerns regarding application of the Mental Capacity Act and restraint training, the Emergency Department together with the Trust’s Safeguarding Team have worked with colleagues at ELFT to review the current provision for staff in the Emergency Department. This has led to amendments which include updates to MCA and restraint training for junior doctors in the Emergency Department and monthly shared learning forums with the PLS and the acute medicine team where particularly complex cases are also reviewed.” Source location Response from Bedfordshire Hospital NHS Foundation 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 Continue joint Trust and ELFT work to embed transfer protocols and improve safety for mental health patient transfers.
Verbatim wording from the response “Collaborative work between the Trust and ELFT will also be ongoing to ensure embedding of protocols and increased safety when it is necessary for mental health patients to be transferred.” Source location Response from Bedfordshire Hospital NHS Foundation 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 the revised Transfer Policy, including requirements and supporting appendices for patients at risk of absconding.
Verbatim wording from the response “We note that at the SI decision panel, PEARL, whilst we did identify that immediate improvements were required to our Transfer Policy, these had not been fully actioned by the time of the inquest. For this we apologise and have included a copy of the revised policy. The policy has been updated in collaboration with colleagues at ELFT and now more fully addresses patient needs. We have added Section 4.7 around patient transfers for those identified at risk of absconding, and Appendices 6, 7 and 8 now support this addition to the policy.” Source location Response from Bedfordshire Hospital NHS Foundation Trust
Open published response
3 Apr 2022 Mandy Jane DICKERSON · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 8 Failure to make, retain and convey documentation of ED streaming decisions View source Failure of the sepsis template to operate reliably and mandatorily View source Lack of a policy directing specialty registrar responses to out-of-hours assessment requests View source Failure to perform critical clinical observations View source Insufficient information gathering during emergency-department streaming to UGPC View source Confusion over escalation and return-to-ED arrangements for out-of-hours specialty referrals View source Failure to convey key clinical information to medical registrars View source Failure to record the identity of medical registrars providing advice View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mandy Jane DICKERSON · 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
Mandy Jane Dickerson attended the Urgent GP Care Centre on 26 April 2020 after several days of diarrhoea and vomiting, but was discharged without assessment by the medical team. She died at home on 30 April 2020 from sepsis. The principal concerns included a non-mandatory and unreliable sepsis template, inadequate recording and communication of key observations, and confusion about referral responsibilities when specialist assessment was requested.
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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make, retain and convey documentation of ED streaming decisions
Wider context from the report “1. I heard detailed evidence of the "streaming" service where patients attending the ED were directed to the UGPC on the basis of very little information gained from their presenting complaint and basic "eyeballing" of the patient. I understood that there is a difference between streaming to UGPC and triage for entry into the ED. I also understood the impact of the pandemic on the provision of services. However, it was apparent that very little documentation of the process with regard to each patient is made, kept or conveyed .
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the sepsis template to operate reliably and mandatorily
Wider context from the report “2. The computer system in use at the Urgent GP Care Centre was prone at the time (April 2020) to glitches which rendered the use of the "Sepsis template" to be "advised" rather than mandatory . Sometimes it would display and other times 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy directing specialty registrar responses to out-of-hours assessment requests
Wider context from the report “2. I have referred in (3) above to the situation with respect to the referrals to the speciality registrars out of hours. I was provided with information about many different policies and procedures but I did not hear evidence as to any policy directing how a speciality registrar should respond to a request for assessment when even allowing for the missing important observations, enough information was conveyed to mandate (in Dr ████████ and Dr ████████ opinions) a medical assessment.
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform critical clinical observations
Wider context from the report “4. There was in my view a failure to record and then to convey key information to the medical registrar who consequently may have given advice which was ill-informed. The nurse practitioner told me, in oral evidence and in a statement provided at the eleventh hour the night before the Inquest, that the measurements had been performed but simply not recorded . However, the remainder of the note was particularly and contemporaneously detailed with these critical observations being conspicuous in their absence. I found that the observations had not been made . In addition, no record was made of the name of the medical registrar making investigation of this element difficult.
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient information gathering during emergency-department streaming to UGPC
Wider context from the report “1. I heard detailed evidence of the "streaming" service where patients attending the ED were directed to the UGPC on the basis of very little information gained from their presenting complaint and basic "eyeballing" of the patient . I understood that there is a difference between streaming to UGPC and triage for entry into the ED. I also understood the impact of the pandemic on the provision of services. However, it was apparent that very little documentation of the process with regard to each patient is made, kept or conveyed.
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Confusion over escalation and return-to-ED arrangements for out-of-hours specialty referrals
Wider context from the report “3. There was fundamental confusion with regard to the management of patients, out of hours, who the treating UGPC clinician felt should be assessed by a relevant specialty , in this case medical, and where the relevant speciality felt assessment was unnecessary. It was understood by ████████ and by the treating UGPC nurse that once the speciality registrar had made a decision then that decision was final and the only option was to discharge the patient , unless they were in extremis, when a 222 call would be made for emergency assistance from the nearby hospital. I was told that if the patient was returned to the ED then the streaming nurse would simply refer them back.
That view was flatly contradicted by Dr ████████, Consultant in Emergency Medicine at the Luton and Dunstable University Hospital and Deputy Medical Director. He told me it was entirely open to the UGPC staff to refer back to ED if there was difficulty . He did not accept that the ED would refuse to see patients referred back, saying it happened all the time.
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to convey key clinical information to medical registrars
Wider context from the report “4. There was in my view a failure to record and then to convey key information to the medical registrar who consequently may have given advice which was ill-informed. The nurse practitioner told me, in oral evidence and in a statement provided at the eleventh hour the night before the Inquest, that the measurements had been performed but simply not recorded. However, the remainder of the note was particularly and contemporaneously detailed with these critical observations being conspicuous in their absence. I found that the observations had not been made. In addition, no record was made of the name of the medical registrar making investigation of this element difficult.
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the identity of medical registrars providing advice
Wider context from the report “4. There was in my view a failure to record and then to convey key information to the medical registrar who consequently may have given advice which was ill-informed. The nurse practitioner told me, in oral evidence and in a statement provided at the eleventh hour the night before the Inquest, that the measurements had been performed but simply not recorded. However, the remainder of the note was particularly and contemporaneously detailed with these critical observations being conspicuous in their absence. I found that the observations had not been made. In addition, no record was made of the name of the medical registrar making investigation of this element difficult.
” 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 Update UGPC streaming guidance and add an addendum requiring clinician agreement or documented disagreement followed by immediate ED referral under Mandy’s Rule.
Verbatim wording from the response “The Trust has worked with Atrumed Healthcare to update the ‘Streaming Guidelines for the Urgent GP Clinic (UGPC)’ (appendix 1) to ensure more clarity in the system for referral from UGPC to the Hospital.” Source location Response from Bedfordshire Hospital NHS Foundation 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 Enable Trust access to SystmOne so streaming information is available for access and review.
Verbatim wording from the response “Streaming is an initial allocation assessment. The streaming nurse records a brief summary on a slip of paper of the 1 minute consultation that is carried out. This slip is handed to the ED receptionist. Where the patient is streamed to UGPC, the receptionist enters details onto SystmOne, UGPC’s patient management software. The clinical information on the slip of paper is also added to SystmOne.” Source location Response from Bedfordshire Hospital NHS Foundation Trust
Open published response
Concerns raised 3 Failure to provide timely Medical Team review and diagnostic support after referral View source Delays in obtaining Neurological opinion alongside relevant imaging View source Failure of the standard referral system to reliably transmit Bedford Neurologist referrals 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.
×
AI-generated summary
Sarah YOUNG · 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
Sarah YOUNG was admitted to Bedford Hospital on 9 April 2019 with headaches, confusion, immobility and fluctuating consciousness, and was later declared to have suffered brain-stem death on 12 April 2019 after an extensive cerebral sinus thrombosis. The principal concerns were delays in medical and neurological review, diagnosis and treatment, including difficulties with the referral system. The Inquest heard that earlier treatment may have increased her chances of survival, but could not be said to have contributed to her death.
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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely Medical Team review and diagnostic support after referral
Wider context from the report “(1) Although Sarah was referred to the Medical Team at 20:00 on 9 April 2019 whilst she still in the Emergency Department awaiting the CT venogram, she was never seen by them . The evidence to the Inquest from the Medical Registrar on call that evening was that “if a decision to admit to ITU is made, an immediate or urgent medical review is not required, as the patient is under the direct care of the ITU team” yet the evidence from one of the ITU Consultants in charge of her care was that the ITU Team do rely on the Medical Team to assist in progressing a diagnosis( including involving a Neurologist where required) and that it was a matter of regret for him that there had not been more Medical advice in this case ;
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining Neurological opinion alongside relevant imaging
Wider context from the report “(2) Although the Neurosurgical Team had advised the Bedford Emergency Department Team at 19.45 hours on 9 April 2019 that a Neurological opinion should be sought alongside the CT venogram, such opinion was not sought until 16.15 hours on 10 April 2019 (the following day) and, even then, only after further prompting from the Neurosurgical Team . The Inquest heard that a Neurological opinion was likely to have involved immediate consultation with the on-call Neuroradiologist which would have resulted in a much earlier diagnosis and treatment of the Cerebral Venous Sinus Thrombosis;
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the standard referral system to reliably transmit Bedford Neurologist referrals
Wider context from the report “(3) The Inquest heard that referrals to the Bedford Neurologist (only available during Monday - Friday working hours) are not always picked up through the standard referral system and often require personal 1:1 contact between clinicians .
” Open source report
Concerns raised 5 Limited critical care outreach authority and initial medical response causing potential delays in life-saving measures View source Failure of serious incident investigations to detect significant safety concerns and learning View source Mismatch between critical care outreach call guidance and nurses’ understanding of the call threshold View source Lack of assessment of staff understanding and training effectiveness for critical care outreach calls View source Failure to accurately record NEWS observations and scores View source See 2 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.
×
AI-generated summary
Pamela Evans · 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
Pamela Evans, aged 87, fell and hit her head at Bedford Hospital after becoming dizzy while walking to the toilet, and died on 4 November 2018 from a large right-sided acute on chronic subdural haematoma. Concerns included inconsistent understanding among nurses about when to call the critical care outreach team, limited action that team could initially take, errors in recording her NEWS, and failures to identify these issues through the Trust’s serious incident investigation.
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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited critical care outreach authority and initial medical response causing potential delays in life-saving measures
Wider context from the report “(iii) Even if the critical care outreach team had been called, a doctor would not initially attend, but rather a critical care nurse with limited power to take action – eg could not request a CT scan . I am therefore concerned that, if the relevant medical team is busy dealing with another emergency, a patient (eg with a head injury needing a CT scan) may still face delay receiving potentially life-saving measures, even if the critical care outreach team is called .
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of serious incident investigations to detect significant safety concerns and learning
Wider context from the report “(v) That points (i)-(iv) had not been detected by the Trust despite its carrying out of a serious incident investigation . I am therefore concerned that significant and potentially life-saving learning may be missed by the Trust in the future even if serious incident investigations are carried out .
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Mismatch between critical care outreach call guidance and nurses’ understanding of the call threshold
Wider context from the report “(i) A mismatch between:
(a) on the one hand, the expressed intention of senior nursing staff as to when nurses should call the critical care outreach team if the relevant medical team is unable to attend, namely that nurses should call when they have concerns about a patient, irrespective of the patient’s NEWS score
and
(b) on the other hand, the understanding of at least some nurses that they cannot or will not call the outreach team, despite having concerns, unless the NEWS score exceeds a specific number (5 or above, according to the cardiac nurse practitioner who cared for the deceased; 7 or above, according to a doctor setting out her experience of some nurses’ practice).
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of assessment of staff understanding and training effectiveness for critical care outreach calls
Wider context from the report “(ii) The absence of a means (eg audit) of assessing the understanding held by those who need to know (eg nurses), of when the critical care outreach team could/should be called ; and therefore a lack of knowledge within the Trust of whether training on this point has been effective and comprehensive to all relevant people or whether further/different training needs to take place .
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record NEWS observations and scores
Wider context from the report “(iv) Incorrect recording of this patient’s NEWS and associated score after her fall which could in other circumstances influence whether/when potentially life-saving measures for future patients take place . Significantly, the deceased’s confusion at some point after 0500 should have been recorded as 3 under D (“consciousness”) but was never noted at all . It was not clear why; the cardiac nurse practitioner was aware of it and thought the clinical support worker completing the chart had been made aware. Further: first, vomiting after 0500 should have given a nausea score of 2 but was only scored 1 ; secondly, while a heart rate of 160 after 0500 was noted in the nursing records, only 93 was recorded in the NEWS observation chart at 0515 .
” Open source report
6 Sep 2019 Millie Creasy · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 3 Failure to consider neuroprotective strategies after prolonged seizure View source Lack of prescriptive clinical treatment guidance for children presenting with prolonged seizure View source Failure to maintain neurological observation after prolonged seizure 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.
×
AI-generated summary
Millie Creasy · 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
Millie Creasy suffered a prolonged seizure at home on 31 July 2018, was discharged from hospital after limited neurological observations, and was readmitted after deteriorating. She subsequently suffered respiratory arrest caused by brain herniation from raised intracranial pressure, and brain stem death was confirmed on 5 August 2018. Concerns included the lack of continued neurological observations, the absence of consideration of neuroprotective strategies after a prolonged seizure, and whether earlier identification and treatment of raised intracranial pressure might have improved her chances of survival.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider neuroprotective strategies after prolonged seizure
Wider context from the report “(1) Millie was admitted to the Luton & Dunstable Hospital on 31 July 2018 at 14.42 hours having suffered a prolonged seizure of approximately 30 minutes which paramedics described as decorticate. She was subsequently discharged at 20.40 hours for with an appointment for review the following day (regular neurological observations had ceased after 2 hours);
(2) Whilst my factual findings recognised that any earlier treatment for raised ICP may not have altered the outcome, and that a diagnosis of raised ICP or the risk of raised ICP is a clinical one, I was informed that it was not possible for the Luton & Dunstable NHS Trust to be more prescriptive in terms of clinical treatment in cases where a child presents with a history of prolonged seizure and that, in any event, “the Trust did not have stronger evidence that a longer period of observation would help as neuro-observations will only detect the late situation when cerebral oedema has reached the point of coning/tonsillar herniation when intervention is often not effective. Additional interventions would only occur when the process is advanced enough for clinical detection and the outcome is poor”;
(3) During the Inquest, I heard evidence from ████████, Paediatric Intensivist, at St Mary’s Hospital, London. Both the Pathologist and ████████ agreed that an prolonged seizure can cause a hypoxic brain injury that may not become clinically apparent for hours or even days. ████████ also explained that if Millie’s condition had been identified at the stage of ‘peri-herniation’, she would have received neuroprotective procedures which would have improved her chances of survival; I have since been provided with a copy of the Imperial College Healthcare NHS Trust Guideline (Drafted by ████████): Neuroprotection for the patient on the Paediatric Intensive Care Unit. The scope of the guideline is said to be multi-protection team working in any area of Paediatrics and states that: “Whenever a patient has suffered a neurological insult or is at risk of primary (cellular damage leading to cell death) or secondary neurological injury (further cellular and structural injury) neuroprotective strategies should be commenced. Clinical situations where this should be considered include the following:
Traumatic Brain Injury
Sepsis – prolonged hypotension
Sepsis – meningitis, encephalitis
Post-cardiac arrest
Any CNS insult – prolonged seizures
Metabolic derangements – sodium, glucose, ammonia
Liver failure – encephalopathy”;
(4) Although the evidence suggested Millie had suffered a prolonged seizure, there was no evidence to suggest the potential need for neuroprotective strategies was, in fact, considered by the Luton & Dunstable NHS Trust .
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of prescriptive clinical treatment guidance for children presenting with prolonged seizure
Wider context from the report “(1) Millie was admitted to the Luton & Dunstable Hospital on 31 July 2018 at 14.42 hours having suffered a prolonged seizure of approximately 30 minutes which paramedics described as decorticate. She was subsequently discharged at 20.40 hours for with an appointment for review the following day (regular neurological observations had ceased after 2 hours);
(2) Whilst my factual findings recognised that any earlier treatment for raised ICP may not have altered the outcome, and that a diagnosis of raised ICP or the risk of raised ICP is a clinical one, I was informed that it was not possible for the Luton & Dunstable NHS Trust to be more prescriptive in terms of clinical treatment in cases where a child presents with a history of prolonged seizure and that, in any event, “the Trust did not have stronger evidence that a longer period of observation would help as neuro-observations will only detect the late situation when cerebral oedema has reached the point of coning/tonsillar herniation when intervention is often not effective. Additional interventions would only occur when the process is advanced enough for clinical detection and the outcome is poor”;
(3) During the Inquest, I heard evidence from ████████, Paediatric Intensivist, at St Mary’s Hospital, London. Both the Pathologist and ████████ agreed that an prolonged seizure can cause a hypoxic brain injury that may not become clinically apparent for hours or even days. ████████ also explained that if Millie’s condition had been identified at the stage of ‘peri-herniation’, she would have received neuroprotective procedures which would have improved her chances of survival; I have since been provided with a copy of the Imperial College Healthcare NHS Trust Guideline (Drafted by ████████): Neuroprotection for the patient on the Paediatric Intensive Care Unit. The scope of the guideline is said to be multi-protection team working in any area of Paediatrics and states that: “Whenever a patient has suffered a neurological insult or is at risk of primary (cellular damage leading to cell death) or secondary neurological injury (further cellular and structural injury) neuroprotective strategies should be commenced. Clinical situations where this should be considered include the following:
Traumatic Brain Injury
Sepsis – prolonged hypotension
Sepsis – meningitis, encephalitis
Post-cardiac arrest
Any CNS insult – prolonged seizures
Metabolic derangements – sodium, glucose, ammonia
Liver failure – encephalopathy”;
(4) Although the evidence suggested Millie had suffered a prolonged seizure, there was no evidence to suggest the potential need for neuroprotective strategies was, in fact, considered by the Luton & Dunstable NHS Trust.
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain neurological observation after prolonged seizure
Wider context from the report “(1) Millie was admitted to the Luton & Dunstable Hospital on 31 July 2018 at 14.42 hours having suffered a prolonged seizure of approximately 30 minutes which paramedics described as decorticate. She was subsequently discharged at 20.40 hours for with an appointment for review the following day (regular neurological observations had ceased after 2 hours );
(2) Whilst my factual findings recognised that any earlier treatment for raised ICP may not have altered the outcome, and that a diagnosis of raised ICP or the risk of raised ICP is a clinical one, I was informed that it was not possible for the Luton & Dunstable NHS Trust to be more prescriptive in terms of clinical treatment in cases where a child presents with a history of prolonged seizure and that, in any event, “the Trust did not have stronger evidence that a longer period of observation would help as neuro-observations will only detect the late situation when cerebral oedema has reached the point of coning/tonsillar herniation when intervention is often not effective. Additional interventions would only occur when the process is advanced enough for clinical detection and the outcome is poor”;
(3) During the Inquest, I heard evidence from ████████, Paediatric Intensivist, at St Mary’s Hospital, London. Both the Pathologist and ████████ agreed that an prolonged seizure can cause a hypoxic brain injury that may not become clinically apparent for hours or even days. ████████ also explained that if Millie’s condition had been identified at the stage of ‘peri-herniation’, she would have received neuroprotective procedures which would have improved her chances of survival; I have since been provided with a copy of the Imperial College Healthcare NHS Trust Guideline (Drafted by ████████): Neuroprotection for the patient on the Paediatric Intensive Care Unit. The scope of the guideline is said to be multi-protection team working in any area of Paediatrics and states that: “Whenever a patient has suffered a neurological insult or is at risk of primary (cellular damage leading to cell death) or secondary neurological injury (further cellular and structural injury) neuroprotective strategies should be commenced. Clinical situations where this should be considered include the following:
Traumatic Brain Injury
Sepsis – prolonged hypotension
Sepsis – meningitis, encephalitis
Post-cardiac arrest
Any CNS insult – prolonged seizures
Metabolic derangements – sodium, glucose, ammonia
Liver failure – encephalopathy”;
(4) Although the evidence suggested Millie had suffered a prolonged seizure, there was no evidence to suggest the potential need for neuroprotective strategies was, in fact, considered by the Luton & Dunstable NHS Trust.
” Open source report
5 Feb 2019 Gwyneth Ann EDWARDS · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 6 Failure to make proper and crucial clinical notes under staffing pressures View source Failure of the transfer solution to include weekend transfers View source Failure of the Mobile Medic System to ensure completion reflects attendance View source Failure to ensure staff know that desmopressin tablets are kept in the fridge View source Insufficient staffing for NEWS monitoring View source Failure to act on NEWS scores in accordance with the NEWS Protocol 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.
×
AI-generated summary
Gwyneth Ann EDWARDS · 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
Gwyneth Ann EDWARDS was admitted to Bedford Hospital on 7 December 2017 and deteriorated after Hydrocortisone and Desmopressin were not dispensed. She developed severe hypernatraemia and died on 14 December 2017 while receiving end-of-life care; the stated cause of death included bronchopneumonia and hypernatraemia, with failure to administer Desmopressin and maintain appropriate fluids. Concerns included gaps in weekend transfer arrangements, NEWS scores not being acted upon, an unverified Mobile Medic review marked complete, staff unfamiliarity with Desmopressin storage, and staffing pressures affecting monitoring and record-keeping.
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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make proper and crucial clinical notes under staffing pressures
Wider context from the report “(5) Witnesses who had not recorded their actions or who had not undertaken NEWS scoring, explained that they were too busy, and indicated there was not enough staff. It is of concern that monitoring, as envisaged by NEWS, cannot take place if there is insufficient staff and it is of concern that proper and crucial notes are not being made due to staffing pressures .
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the transfer solution to include weekend transfers
Wider context from the report “(1) The Serious Incident Investigation Report (SIR) addressed the issue of transfers from out of the Acute Assessment Unit (AAU), but the current solution does not include weekend transfers , which is when the deceased was transferred.
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Mobile Medic System to ensure completion reflects attendance
Wider context from the report “(3) During the SIR Investigation it became clear that the Mobile Medic System had registered a request for a review due to raised NEWS at 19.48 hours on 10th December 2017. The Mobile Medic System was marked as complete at 20.54 hours, but there is no record of the Mobile Medic having attended . It is of concern that this request can be marked as complete when it was 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff know that desmopressin tablets are kept in the fridge
Wider context from the report “(4) Desmopressin tablets are kept in the fridge, but the staff were not familiar with the drug to know that . There appears to be no warning on the drug charts that this is the case .
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing for NEWS monitoring
Wider context from the report “(5) Witnesses who had not recorded their actions or who had not undertaken NEWS scoring, explained that they were too busy, and indicated there was not enough staff. It is of concern that monitoring, as envisaged by NEWS, cannot take place if there is insufficient staff and it is of concern that proper and crucial notes are not being made due to staffing pressures.
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on NEWS scores in accordance with the NEWS Protocol
Wider context from the report “(2) The SIR recommended that laminated cards be given to staff with National Early Warning Score (NEWS) scoring and response guidance. It is clear from the evidence of the nurses at the Inquest that the NEWS scoring was being recorded, but not actioned in accordance with the NEWS Protocol . This would suggest that the SIR recommendations to re-inforce learning is not effective.
” Open source report
19 Jun 2017 PATRICK NEIL WOODS · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 4 Lack of knowledge of the equipment portfolio View source Ineffective training on equipment View source Failure to identify potentially dangerous equipment View source Failure to undertake risk assessments for equipment that could potentially kill a patient View source See 1 more concern
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. 4
Action
Review each clinical area, cross-check equipment sub-lists, and update the Trust master equipment log to create a complete and current equipment register.
Stated plannedThe respondent said that this action was planned when they made their response on 19 June 2017. View source
Action
Require clinical directors and matrons to risk-assess identified equipment, review unused functionality, and report findings through the Medical Equipment Group.
Stated plannedThe respondent said that this action was planned when they made their response on 19 June 2017. View source
Action
Introduce TCA checks covering equipment training, machine checks and alarm reviews within routine anaesthetic practice and pre-operative huddles.
Stated plannedThe respondent said that this action was planned when they made their response on 19 June 2017. View source
Action
Implement a procedure to record new equipment on master and area sub-lists, maintain both lists, obtain procurement exception reports, and review their accuracy regularly.
Stated plannedThe respondent said that this action was planned when they made their response on 19 June 2017. View source See 1 more action
×
AI-generated summary
PATRICK NEIL WOODS · 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
PATRICK NEIL WOODS was admitted to hospital with a cough, deteriorated while being treated with a Dräger Tiro Anaesthetic Machine, suffered cardiac arrest, and died from hypoxic brain injury on 15 February 2016. Concerns included the hospital’s lack of knowledge about its equipment portfolio, inadequate risk assessment, and ineffective training that meant clinicians were not trained on, or did not recognise the risks of, the machine used.
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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of the equipment portfolio
Wider context from the report “(1) The extent of the equipment portfolio held by the Hospital seemed to be unknown
(2) Without the knowledge of the equipment held, no potentially dangerous equipment can be identified
(3) Without the knowledge that there is equipment that could potentially kill a patient, no risk assessment can be undertaken
(4) Without a risk assessment, no action can be taken to prevent further injury to patients or fatalities
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective training on equipment
Wider context from the report “(1) The evidence of 4 clinicians at the inquest would suggest that the training by Dräger was not effective .
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify potentially dangerous equipment
Wider context from the report “(1) The extent of the equipment portfolio held by the Hospital seemed to be unknown
(2) Without the knowledge of the equipment held, no potentially dangerous equipment can be identified
(3) Without the knowledge that there is equipment that could potentially kill a patient, no risk assessment can be undertaken
(4) Without a risk assessment, no action can be taken to prevent further injury to patients or fatalities
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake risk assessments for equipment that could potentially kill a patient
Wider context from the report “(1) The extent of the equipment portfolio held by the Hospital seemed to be unknown
(2) Without the knowledge of the equipment held, no potentially dangerous equipment can be identified
(3) Without the knowledge that there is equipment that could potentially kill a patient, no risk assessment can be undertaken
(4) Without a risk assessment, no action can be taken to prevent further injury to patients or fatalities
” 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 Review each clinical area, cross-check equipment sub-lists, and update the Trust master equipment log to create a complete and current equipment register.
Verbatim wording from the response “Further action | Timescale
There is to be a review of each clinical area where an item of equipment is used, to ensure that the Trust has a complete and up to date “master” log of the equipment held.” Source location 2017-0434-Response-by-Luton-Dunstable-University-Hospital
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 Require clinical directors and matrons to risk-assess identified equipment, review unused functionality, and report findings through the Medical Equipment Group.
Verbatim wording from the response “By the end of October 2017, a request will be sent to the Clinical Director and Matron of each clinical area which has a “sub list”, who will then be responsible for undertaking a risk assessment of the identified equipment in their area and to review the unused functionality of said equipment / device. | The risk assessments must take place by the end of January 2018.” Source location 2017-0434-Response-by-Luton-Dunstable-University-Hospital
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 TCA checks covering equipment training, machine checks and alarm reviews within routine anaesthetic practice and pre-operative huddles.
Verbatim wording from the response “Notices have been placed in each anaesthetic room to remind anaesthetists of the importance of ensuring they have received training on all pieces of equipment they are going to use, that they have checked the anaesthetic machine, and that they have reviewed the alarm settings. This TCA (Trained / Checked Machine / Alarms) methodology will become part of the routine practice of anaesthesia at the Luton & Dunstable Hospital, and will become part of the pre-operative huddle that occurs before the start of every list, including emergencies.” Source location 2017-0434-Response-by-Luton-Dunstable-University-Hospital
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 a procedure to record new equipment on master and area sub-lists, maintain both lists, obtain procurement exception reports, and review their accuracy regularly.
Verbatim wording from the response “From October 2017 the Trust will implement a new procedure whereby:” Source location 2017-0434-Response-by-Luton-Dunstable-University-Hospital
Open published response
Concerns raised 1 Lack of a robust system for carrying out urgent tests and imaging without delay at weekends View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David MOSTARI · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David MOSTARI was admitted to Bedford Hospital on 8 August 2015 with a suspected flare-up of ulcerative colitis, deteriorated, and was found to have a perforated colon with widespread faecal contamination. He died on 10 August 2015 after treatment was withdrawn. The concerns included delays in carrying out urgent imaging following his weekend admission and failures to recognise the seriousness of his condition and take necessary treatment steps.
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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust system for carrying out urgent tests and imaging without delay at weekends
Wider context from the report “1. Mr. Mostari was admitted to the Hospital on a Saturday and despite the need for an urgent x-ray and ultra sound scan the tests were not in fact carried out until the Monday. There therefore does not appear to be any robust system in place for ensuring that urgent tests and imaging are carried out without delay, particularly when a patient is admitted at the week-end. The deceased needed the tests and follow up treatment as a matter of urgency.
” 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 Provide 24/7 on-site or on-call plain-X-ray radiography.
Verbatim wording from the response “Imaging” Source location D-Mostari-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 Introduce and roll out online electronic requesting for radiological examinations, with training.
Verbatim wording from the response “General
Electronic reporting and availability of images has been in place for several years
On-line electronic requesting of radiological examinations to be introduced and rolled out in starting in April 2016. Training provided” Source location D-Mostari-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 Enable requests for fluoroscopy and special procedures through on-call consultant and radiologist discussion.
Verbatim wording from the response “Fluoroscopy, Special procedures (e.g. Barium enema, nephrostomy),
Requests can be made via on-call consultant discussion with an on call radiologist for imaging of any patient.” Source location D-Mostari-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 Maintain electronic radiology reporting and image availability.
Verbatim wording from the response “General
Electronic reporting and availability of images has been in place for several years
On-line electronic requesting of radiological examinations to be introduced and rolled out in starting in April 2016. Training provided” Source location D-Mostari-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 Keep the laboratory open and staffed continuously for specimen testing.
Verbatim wording from the response “Pathology” Source location D-Mostari-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 Include investigation-service details and access arrangements in new doctor locum packs available on the Trust intranet.
Verbatim wording from the response “Details of these services and how to access them have since February 2016 been included in the new doctor locum packs available on the Trust’s intranet.” Source location D-Mostari-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 Provide ultrasound imaging through on-call consultant and radiologist discussion, seven days a week year-round.
Verbatim wording from the response “Ultrasound imaging” Source location D-Mostari-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 Audit the electronic medical handover process as part of the serious-incident action plan.
Verbatim wording from the response “Under the Hospital at Night development, an electronic handover sheet has been developed, to highlight outstanding tests/results to doctors on change of shift to ensure that investigations are pursued/ acted on - sample attached.” Source location D-Mostari-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 Use an electronic medical handover sheet to highlight outstanding tests and results for follow-up at shift changes.
Verbatim wording from the response “Medical Handover” Source location D-Mostari-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 Publicise imaging service details and requesting arrangements on the Trust intranet.
Verbatim wording from the response “Full details of services available and requesting arrangements now publicised on trust intranet.” Source location D-Mostari-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 Provide expanded endoscopy services from 8am to 8pm, seven days a week, following department refurbishment and extension.
Verbatim wording from the response “Endoscopy” Source location D-Mostari-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 Provide routine weekend CT lists and 24/7 on-call CT access, including consultant and radiologist escalation.
Verbatim wording from the response “CT scanning” Source location D-Mostari-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 Provide seven-day MRI access, on-call radiologist advice, and specialist-centre transfer when emergency out-of-hours MRI is unavailable.
Verbatim wording from the response “MRI Imaging” Source location D-Mostari-Response
Open published response
Concerns raised 3 Failure to provide further support to midwives without experience in newborn resuscitation View source Failure of the Supervisors of Midwives system to support pregnant women and midwives View source Failure to take individual midwife experience into account when allocating women on shifts 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.
×
AI-generated summary
Willow Davies · 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
Willow Davies was born at Bedford Hospital on 8 February 2014 and became pale and floppy shortly afterwards; CPR was commenced, and her death was confirmed later that morning. The substantive concerns related to the allocation and support of a newly qualified midwife who had no prior experience assisting with newborn resuscitation, the failure to account for midwives’ experience when allocating women, and the operation of the Supervisors of Midwives system.
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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide further support to midwives without experience in newborn resuscitation
Wider context from the report “1. That a newly qualified Midwife was allocated to deliver a baby when, during the course of her training and her practice since qualifying, she had never assisted with the resuscitation of a new born baby . The Midwife had no further support .
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Supervisors of Midwives system to support pregnant women and midwives
Wider context from the report “3. That system of ‘Supervisors of Midwives’, as it operates at Bedford Hospital, is in urgent need of review to ensure that it is working to support pregnant women and midwives in the Trust .
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to take individual midwife experience into account when allocating women on shifts
Wider context from the report “2. That the allocation of women to midwives on a shift by shift basis did not, and does not, take into account the experience of the individual midwife
” Open source report
Concerns raised 2 Failure of the Haematology Department to remain contactable by attending doctors View source Failure of Haematologists to respond to requests for advice and review 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.
×
AI-generated summary
Sonielia Laura Caya HOLMES · 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
Sonielia Laura Caya HOLMES was admitted to Bedford Hospital on 17 April 2013 with confusion and seizures, later suffering a fall that caused a brain bleed. She died from multi-organ failure at 17:06 on 4 May 2013. The principal concerns were repeated failures to contact Haematology doctors and failures to respond to requests for advice and review, despite the use of known contact details.
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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Haematology Department to remain contactable by attending doctors
Wider context from the report “1. That on numerous occasions it proved impossible for the doctors attending Miss Holmes to contact the Haematology Department at the Hospital . This was despite the staff using all known contact details, including mobile phones and bleep numbers .
2. That the Haematologists working within the Hospital failed to respond to messages left for them to offer advice and to review Miss Holmes.
3. It was apparent from the evidence that Haematology is a vital service within the Hospital and any failure to respond to requests for assistance from other clinicians will put lives at risk.
” 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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Haematologists to respond to requests for advice and review
Wider context from the report “1. That on numerous occasions it proved impossible for the doctors attending Miss Holmes to contact the Haematology Department at the Hospital. This was despite the staff using all known contact details, including mobile phones and bleep numbers.
2. That the Haematologists working within the Hospital failed to respond to messages left for them to offer advice and to review Miss Holmes .
3. It was apparent from the evidence that Haematology is a vital service within the Hospital and any failure to respond to requests for assistance from other clinicians will put lives at risk .
” Open source report
2 Jun 2014 Essa Shah · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1 Failure to provide co-sleeping danger literature for discharged new mothers in languages other than English 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.
×
AI-generated summary
Essa Shah · 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
Essa Shah, aged eight weeks, went to sleep in the same bed as his mother following a feed and was later found unresponsive. The report raised concern that hospital literature about the dangers of co-sleeping was available only in English.
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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide co-sleeping danger literature for discharged new mothers in languages other than English
Wider context from the report “1. That the literature, setting out the dangers of co-sleeping which the hospital hand to new mothers being discharged, is only available in the English Language .
” Open source report
2 Jun 2014 Aimee Sarah VARNEY · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1 Failure to follow NICE referral guidelines for patients with suspected epilepsy to a Specialist Tertiary Centre View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Aimee Sarah VARNEY · 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
Aimee Sarah VARNEY died following a seizure from Sudden Unexpected Death in Epilepsy at her home address. The report identifies a concern that NICE guidance on referring patients with suspected epilepsy to a Specialist Tertiary Centre was not followed, and states that this represented a lost opportunity to diagnose and further treat her condition.
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 Bedfordshire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow NICE referral guidelines for patients with suspected epilepsy to a Specialist Tertiary Centre
Wider context from the report “1. That the NICE Guidelines for referring a patient with suspected epilepsy to a Specialist Tertiary Centre were not followed .
” Open source report
×
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 Existing systems for logging, disseminating and monitoring NICE guidelines are considered appropriate.
Verbatim wording from the response “The Medical Director is responsible for ensuring every new NICE guideline is allocated to the relevant speciality. The appropriate Clinical Audit and Effectiveness Committee (CAEC) Lead, the Finance and the Clinical Director all receive copies for discussion and dissemination. As for all NHS bodies there are occasions where the hospital cannot immediately comply with NICE guidance. This can be due to resources and requires negotiation with our commissioners to fund, for example, high value new drug therapies.” Source location 2014-0249-Response-by-Luton-Dunstable-University-Hospital
Open published response
×
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 NICE guidelines do not require rigid compliance; clinicians may appropriately depart from recommendations using professional clinical judgment.
Verbatim wording from the response “However it must be emphasised that they are guidelines, not tramlines that the treating clinician must rigidly follow. NICE state “...health and social care professionals are actively encouraged to follow our recommendations to help them deliver the highest quality care. Of course, our recommendations are not intended to replace the professional expertise and clinical judgement of health professionals, as they discuss treatment options with their patients.” There will be individual patients where the treating clinician uses their own judgement and does not follow the absolute guidance.” Source location 2014-0249-Response-by-Luton-Dunstable-University-Hospital
Open published response
Pin
Request correction
Addressed to Bedford Hospital NHS Trust, now represented here by Bedfordshire Hospitals NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations