Recipient

Birmingham Children's Hospital

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First report 7 May 2021•Latest report 7 May 2021

Recipient record

Reports, concerns and published responses

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

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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 Birmingham Children's Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Alex Louise Shaw · 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

    Alex Louise Shaw, who had methylmalonic aciduria and chronic kidney failure, died on 22 October 2018 after developing fluid overload, pulmonary oedema and respiratory failure during hospital treatment. The principal concerns were poor communication and documentation of her clinical observations and telephone advice between clinicians at Royal Stoke University Hospital and Birmingham Children’s Hospital, including failure to communicate her rising heart rate.

    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 Birmingham Children's Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consistently document the content and timing of inter-hospital clinical conversations

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) There was poor communication of the patient’s clinical condition/observations between the Registrar at the Royal Stoke University Hospital and the Consultant at the Birmingham Children’s Hospital when advice was sought by telephone. There was also poor documentation of the contents of the information that had been provided during that conversation and the timing of when the call was made. The evidence of the Consultant at the Birmingham Children’s Hospital was that her advice would have been different if she had been made aware of the patient’s rising heart rate. (2) The evidence also revealed it was a “judgment call” when the clinician felt that a dialogue between clinician’s at a different hospital needed to be documented. (3) Consideration should be given as to how a patient’s observations are communicated to the clinician’s between the University Hospital and the Birmingham Children’s Hospital, the time, content, advice and documentation of the conversations. ”
    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 Birmingham Children's Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate patients’ clinical condition and observations between clinicians when telephone advice is sought

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) There was poor communication of the patient’s clinical condition/observations between the Registrar at the Royal Stoke University Hospital and the Consultant at the Birmingham Children’s Hospital when advice was sought by telephone. There was also poor documentation of the contents of the information that had been provided during that conversation and the timing of when the call was made. The evidence of the Consultant at the Birmingham Children’s Hospital was that her advice would have been different if she had been made aware of the patient’s rising heart rate. (2) The evidence also revealed it was a “judgment call” when the clinician felt that a dialogue between clinician’s at a different hospital needed to be documented. (3) Consideration should be given as to how a patient’s observations are communicated to the clinician’s between the University Hospital and the Birmingham Children’s Hospital, the time, content, advice and documentation of the conversations. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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