13 Feb 2024 Michael James NYE · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 7 Delays in completion of night-time blood tests View source Lack of effective night-time Internal Escalation Policy measures View source Delays in notification of abnormal blood test results to clinicians View source Lack of clinician training and education on atypical sepsis presentation and recognition of sepsis with high lactate View source Lack of contemporaneous record keeping in the Emergency Department View source Lack of training of Intensive Care Unit clinicians on the policy requiring review after a "just to let you know" call View source Burdensome and time-consuming out-of-hours CT scan requesting system View source See 4 more concerns
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
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations