Recipient

Berkshire and Surrey Pathology Services

First report 13 Feb 2024•Latest report 13 Feb 2024

Recipient record

Reports, concerns and published responses

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

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Berkshire and Surrey Pathology Services linked to the concerns in each report. Select any concern, action or position to view the source wording.

13 Feb2024
Berkshire
Concerns raised7
1. Delays in completion of night-time blood tests
2. Lack of effective night-time Internal Escalation Policy measures
3. Delays in notification of abnormal blood test results to clinicians
1. Lack of clinician training and education on atypical sepsis presentation and recognition of sepsis with high lactate
2. Lack of contemporaneous record keeping in the Emergency Department
3. Lack of training of Intensive Care Unit clinicians on the policy requiring review after a "just to let you know" call
4. Burdensome and time-consuming out-of-hours CT scan requesting system
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

Michael James NYE · 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

Michael James Nye attended the Royal Berkshire Hospital with sepsis caused by a Streptococcus A skin and soft tissue infection, but was initially diagnosed with an upper arm DVT. His condition deteriorated and he suffered two cardiac arrests, with his death verified on 15 November 2022. Concerns included delays in blood tests, CT scanning, escalation to the Intensive Care Unit and prescribing antibiotics, as well as overcrowding, inadequate escalation arrangements and training needs concerning atypical sepsis.

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 Berkshire and Surrey Pathology Services; that does not assign responsibility.
PFD Monitor interpretation
Delays in completion of night-time blood tests
Wider context from the report
“a. Delays in blood tests being completed at night at the Royal Berkshire Hospital, and notification to clinicians on the Electronic Patient Record of abnormal results which are being reviewed. ”
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 Berkshire and Surrey Pathology Services; that does not assign responsibility.
PFD Monitor interpretation
Lack of effective night-time Internal Escalation Policy measures
Wider context from the report
“d. The lack of a specific night time Internal Escalation Policy. A number of the general Internal Escalation Policy measures are not effective at night; ”
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 Berkshire and Surrey Pathology Services; that does not assign responsibility.
PFD Monitor interpretation
Delays in notification of abnormal blood test results to clinicians
Wider context from the report
“a. Delays in blood tests being completed at night at the Royal Berkshire Hospital, and notification to clinicians on the Electronic Patient Record of abnormal results which are being reviewed. ”
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 Berkshire and Surrey Pathology Services; that does not assign responsibility.
PFD Monitor interpretation
Lack of clinician training and education on atypical sepsis presentation and recognition of sepsis with high lactate
Wider context from the report
“f. The need for training and education of all clinicians on atypical presentation of sepsis and the need for a high index of suspicion for sepsis, particularly in the presence of a high lactate. ”
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 Berkshire and Surrey Pathology Services; that does not assign responsibility.
PFD Monitor interpretation
Lack of contemporaneous record keeping in the Emergency Department
Wider context from the report
“c. The lack of contemporaneous record keeping in the Emergency Department; ”
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 Berkshire and Surrey Pathology Services; that does not assign responsibility.
PFD Monitor interpretation
Lack of training of Intensive Care Unit clinicians on the policy requiring review after a "just to let you know" call
Wider context from the report
“e. The need for training of all Intensive Care Unit clinicians at all levels, both existing Intensive Care Unit clinicians and new joiners, in the policy that a "just to let you know" call should result in an Intensive Care review of the patient; ”
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 Berkshire and Surrey Pathology Services; that does not assign responsibility.
PFD Monitor interpretation
Burdensome and time-consuming out-of-hours CT scan requesting system
Wider context from the report
“b. The burdensome and time consuming out of hours system for clinicians requesting CT scans from an external provider; ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised7

Delays in completion of night-time blood tests

Lack of effective night-time Internal Escalation Policy measures

Delays in notification of abnormal blood test results to clinicians

Lack of clinician training and education on atypical sepsis presentation and recognition of sepsis with high lactate

Lack of contemporaneous record keeping in the Emergency Department

Lack of training of Intensive Care Unit clinicians on the policy requiring review after a "just to let you know" call

Burdensome and time-consuming out-of-hours CT scan requesting system