4 Nov 2025 Mrs Maureen Christy · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 1 Shortcomings in dissemination of clinical-care policy and practice changes View source
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. 3
Action
Implement structured dissemination of clinical policy changes through central coordination, digital alerts, manager briefings, safety huddles, meetings, rapid training and e-learning.
Stated completedThe respondent said that this action was complete when they made their response on 7 November 2025. View source
Action
Roll out Alertive to issue critical messages, record staff acknowledgements, and subsequently scope its use for cascading policy documents.
Stated plannedThe respondent said that this action was planned when they made their response on 7 November 2025. View source
Action
Refine policy document control, approval, risk stratification, communication, intranet access, training linkage and compliance oversight through established committees and supporting teams.
Stated completedThe respondent said that this action was complete when they made their response on 7 November 2025. View source
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AI-generated summary
Mrs Maureen Christy · 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
Mrs Maureen Christy fell at home in November 2020, sustained a hip fracture, and was admitted to hospital. She contracted hospital-acquired Covid-19 after exposure on a hospital ward and later died at home; the narrative records conflicting dates for her death and verification of death. The principal concern was shortcomings in the dissemination and understanding of policy and practice changes, including guidance concerning the testing of people identified as Covid contacts.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Shortcomings in dissemination of clinical-care policy and practice changes
Wider context from the report “(3) The policy change concerned was not acted upon in the case of the Deceased at the time of her being identified as a “Covid contact”. Notwithstanding the Trust’s recognition of the need to strengthen the dissemination of policy and practice changes, confusion around the dissemination of that policy or practice change, persisted to the time of evidence being given in this inquest .
(4) Whereas steps are already being taken to address the issue of the dissemination of policy and practice changes, this investigation has revealed matters giving rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, by reason of shortcomings in the dissemination of policy and practice changes pertaining to clinical care .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement structured dissemination of clinical policy changes through central coordination, digital alerts, manager briefings, safety huddles, meetings, rapid training and e-learning.
Verbatim wording from the response “To address these challenges, the Trust implemented a structured approach to policy dissemination:” Source location Response from Blackpool Teaching Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out Alertive to issue critical messages, record staff acknowledgements, and subsequently scope its use for cascading policy documents.
Verbatim wording from the response “The Trust has recognised that further steps could be taken in evidencing that staff have accessed and read all policies which are critical to their role. To create this enhanced oversight, the Trust has plans to roll out a digital solution from Q4 2025/2026 called ‘Alertive’, which allows key critical messages to be issued to all staff with staff acknowledgements of these messages recorded. Whilst the first phase of the implementation will focus on operational processes within the Emergency Department, future phases will include the scoping of the cascade of policy documents to staff, which will begin from Q1 2026/2027.” Source location Response from Blackpool Teaching Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refine policy document control, approval, risk stratification, communication, intranet access, training linkage and compliance oversight through established committees and supporting teams.
Verbatim wording from the response “The Trust recognises the importance of learning from these experiences. Since the COVID pandemic, a number of refinements have been made to the Trust’s document control process, ensuring that these are reviewed, updated and approved within a robust process, and that new and updated documents are effectively communicated to staff.” Source location Response from Blackpool Teaching Hospitals NHS Foundation Trust
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5 Jun 2025 Thomas William OLDCORN · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 1 Delays in surgery beyond 7 days from angiography View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Thomas William OLDCORN · 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
Thomas William Oldcorn was admitted with cardiac symptoms, diagnosed with a non-ST elevation myocardial infarction, and later found to have severe left main stem coronary artery disease. He died of a cardiac arrest while awaiting cardiac MRI and coronary artery bypass surgery. The report raised concern that surgery waiting times exceeded the national seven-day target and that inadequate resources prevented the target from being met; it stated that the inability to perform surgery within the target contributed to his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in surgery beyond 7 days from angiography
Wider context from the report “(1) I heard evidence during the course of Mr Oldcorn's inquest that despite National targets of 7 days from angiography to surgery at the time of his death the waiting time for surgery was 14 days, that it has since risen to 17 days and that there are inadequate resources to meet the national target.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a dashboard, dedicated coordinator and consultant-led RAG review to monitor urgent CABG patients and identify delays.
Verbatim wording from the response “A dashboard is in place to track all patients awaiting urgent CABG surgery, enabling proactive management and early identification of any potential delays. We have a dedicated nursing co-ordinator for inpatients who works closely with our dedicated Cardiothoracic Consultant Surgeon in-patient lead to regularly review each patient, monitoring their clinical priority and establishing a collective clinical overview. This review is captured on a RAG-rated system, with red/critical patients being given higher priority.” Source location Response from Blackpool Teaching Hospital NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and ratify an escalation policy for daily senior-clinician review and prioritisation before patients reach the seven-day threshold.
Verbatim wording from the response “The above immediate action, implemented as a test of change, will now be formalised with the development of an escalation policy to ensure that any patient approaching the 7-day threshold is reviewed daily by a senior clinician and prioritised accordingly. The Trust will have the policy completed and ratified by September 2025.” Source location Response from Blackpool Teaching Hospital NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct monthly audits, monitor incidents and harms, and report findings through Trust governance committees to adjust provision.
Verbatim wording from the response “Monthly audits are being conducted and monitoring of incidents and harms, with findings reported to the Trust Risk Committee, Clinical Governance Committee and Performance meetings with appropriate adjustments to the provision made.” Source location Response from Blackpool Teaching Hospital NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit and appoint a Consultant Anaesthetist to strengthen cardiothoracic service capacity.
Verbatim wording from the response “Whilst the service is planned to run on 50 weeks of the year, the job plans of both the Consultant Anaesthetists and Surgeons are based on 42 weeks so both flexible job sessions and cross cover are utilised in order to maintain the activity against plan. The Trust has recruited a Consultant Surgeon who commenced in post on 7th July 2025, and a Consultant Anaesthetist who is due to commence in post on 25th August 2025. Consultant annual leave policies at sub-speciality levels have been aligned to reduce the impact seen from lack of surgeon availability. In addition, the staffing levels across Theatres and Cardiac Intensive care have been authorised to recruit to the workforce gaps previously seen.” Source location Response from Blackpool Teaching Hospital NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish quality-improvement methodology to oversee compliance with national urgent cardiac-surgery targets.
Verbatim wording from the response “Quality improvement methodology has been established to oversee compliance with national targets for urgent cardiac surgery.” Source location Response from Blackpool Teaching Hospital NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Align subspecialty consultant annual-leave policies to reduce surgeon-availability gaps.
Verbatim wording from the response “Whilst the service is planned to run on 50 weeks of the year, the job plans of both the Consultant Anaesthetists and Surgeons are based on 42 weeks so both flexible job sessions and cross cover are utilised in order to maintain the activity against plan. The Trust has recruited a Consultant Surgeon who commenced in post on 7th July 2025, and a Consultant Anaesthetist who is due to commence in post on 25th August 2025. Consultant annual leave policies at sub-speciality levels have been aligned to reduce the impact seen from lack of surgeon availability. In addition, the staffing levels across Theatres and Cardiac Intensive care have been authorised to recruit to the workforce gaps previously seen.” Source location Response from Blackpool Teaching Hospital NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit and appoint a Consultant Surgeon to strengthen cardiothoracic service capacity.
Verbatim wording from the response “Whilst the service is planned to run on 50 weeks of the year, the job plans of both the Consultant Anaesthetists and Surgeons are based on 42 weeks so both flexible job sessions and cross cover are utilised in order to maintain the activity against plan. The Trust has recruited a Consultant Surgeon who commenced in post on 7th July 2025, and a Consultant Anaesthetist who is due to commence in post on 25th August 2025. Consultant annual leave policies at sub-speciality levels have been aligned to reduce the impact seen from lack of surgeon availability. In addition, the staffing levels across Theatres and Cardiac Intensive care have been authorised to recruit to the workforce gaps previously seen.” Source location Response from Blackpool Teaching Hospital NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Authorize recruitment to address identified Theatre and Cardiac Intensive Care workforce gaps.
Verbatim wording from the response “Whilst the service is planned to run on 50 weeks of the year, the job plans of both the Consultant Anaesthetists and Surgeons are based on 42 weeks so both flexible job sessions and cross cover are utilised in order to maintain the activity against plan. The Trust has recruited a Consultant Surgeon who commenced in post on 7th July 2025, and a Consultant Anaesthetist who is due to commence in post on 25th August 2025. Consultant annual leave policies at sub-speciality levels have been aligned to reduce the impact seen from lack of surgeon availability. In addition, the staffing levels across Theatres and Cardiac Intensive care have been authorised to recruit to the workforce gaps previously seen.” Source location Response from Blackpool Teaching Hospital NHS Foundation Trust
Open published response
23 Jan 2025 Brian Kneale · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Inaccurate recording of fluid balances for internal hospital reviews View source Ineffective monitoring of fluid balances View source Absence of important information for clinical decisions about fluid balances View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Brian Kneale · 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
Brian Kneale, aged 70, attended hospital after more than a week of illness, including vomiting and worsening shortness of breath, and died on 29 June 2024. The report records concerns that he received fluids contributing to worsening heart failure and that fluid balance monitoring and recording were not sufficiently accurate, leaving clinicians without important information and affecting the reliability of internal hospital reviews.
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× 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of fluid balances for internal hospital reviews
Wider context from the report “3. Inaccurate recording of fluid balances can leave the authors of internal hospital reviews without the information they require to ensure the correct lessons are learned .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective monitoring of fluid balances
Wider context from the report “1. Fluid balances are not being monitored as effectively as they ought to be ;
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of important information for clinical decisions about fluid balances
Wider context from the report “2. In the absence of more accurate monitoring of fluid balances , clinicians may find themselves making difficult decisions in the absence of important information ;
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the launched Clinical Community to scale, spread and embed fluid-balance improvements across the organisation.
Verbatim wording from the response “A Clinical Community has been launched in February 2025, with an aim to scale, spread and embed the fluid balance work across the organisation.” Source location Response from Blackpool Teaching Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a lead team to update the Trust fluid-balance policy using Quality Improvement recommendations.
Verbatim wording from the response “Our next steps on our improvement journey in relation to fluid balance monitoring includes setting up a Lead team to update the Trust’s Fluid Balance policy which will adopt the recommendations from our Quality Improvement projects.” Source location Response from Blackpool Teaching Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt the designed and tested fluid-balance escalation process.
Verbatim wording from the response “• A fluid balance escalation process has been designed, tested and is now ready for adoption.” Source location Response from Blackpool Teaching Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement trialled risk-stratified fluid monitoring with mandatory dynamic daily risk assessment.
Verbatim wording from the response “The final driver for this workstream is around accurate fluid balance monitoring in patients who require it. This involves risk stratifying fluid balance monitoring based on individual patient’s needs, ensuring there is a minimum of 4 hourly monitoring for those who require fluid balance monitoring and ensuring outputs are monitored and documented accurately. Also importantly, ensuring that discrepancies in fluid balance are escalated appropriately.” Source location Response from Blackpool Teaching Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain organisation-wide line of sight over fluid-balance chart completion through the updated record-keeping audit methodology.
Verbatim wording from the response “Although the Trust has had in place a Record Keeping Audit for a number of years, the methodology has been reviewed and updated to ensure that from 1 April 2025 direct line of sight on the completion of fluid balance charts is maintained across the organisation. This will enhance the local audits in place within the Emergency Department such as the Care and Consistency audits which reviews fluid balance on a daily basis.” Source location Response from Blackpool Teaching Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the newly developed Trust fluid-balance chart across the organisation.
Verbatim wording from the response “A new fluid balance chart has been developed for the Trust which includes colour coding for faster identification, an Acute Kidney Injury (AKI) staging section, a section for evidencing escalation of concerns and balances > or < 1000mls, a section for highlighting fluid restrictions, a section on national quality measures and a list of nephrotoxic/nephrosensitive medications to support medicines management for patients with AKI. This will shortly be rolled out across the Trust.” Source location Response from Blackpool Teaching Hospitals NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce mandatory afternoon checks and QR-code guidance to reinforce fluid-balance policy changes.
Verbatim wording from the response “The new Trust policy will also include mandatory afternoon checks and there will be a widespread introduction which will be accompanied by a QR code for staff, to reinforce changes and expectations.” Source location Response from Blackpool Teaching Hospitals NHS Foundation Trust
Open published response
12 Jul 2024 Sandra Phillpott · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2 Delays in providing urgent treatment for suspected sepsis View source Failure to recognize suspected sepsis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sandra Phillpott · 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
Sandra Phillpott died on 31 October 2023 after developing sepsis and multi-organ failure following E. coli O157 and pneumococcal infections. The report identifies delays in recognising suspected sepsis and providing antibiotics and intravenous fluids, with attention initially focused on ruling out pulmonary embolism and deep vein thrombosis.
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× 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in providing urgent treatment for suspected sepsis
Wider context from the report “• The concern relates to the recognition of suspected sepsis, and the need for timely provision of treatment for suspected sepsis .
• Notwithstanding that I determined that from the available evidence timely treatment would not have altered the fatal outcome, I remain firmly of the view this report is necessary.
• I was informed at the inquest that there have been significant improvements in the management of sepsis within the Emergency Department.
• This court has raised concerns with the hospital Trust about this issue previously, and I know it is an issue which the Trust is very aware of and I do not doubt that efforts have been made to make improvements, but having conducted this inquest into Sandra’s death, in my view there remains a risk that sepsis will go unrecognized, and urgent treatment will be delayed , putting patients attending Blackpool Victoria Hospital at risk. My duty to write this report is therefore met. It is not for me to be prescriptive about what action ought to be taken, but to raise this concern should I feel this is necessary.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognize suspected sepsis
Wider context from the report “• The concern relates to the recognition of suspected sepsis , and the need for timely provision of treatment for suspected sepsis.
• Notwithstanding that I determined that from the available evidence timely treatment would not have altered the fatal outcome, I remain firmly of the view this report is necessary.
• I was informed at the inquest that there have been significant improvements in the management of sepsis within the Emergency Department.
• This court has raised concerns with the hospital Trust about this issue previously, and I know it is an issue which the Trust is very aware of and I do not doubt that efforts have been made to make improvements, but having conducted this inquest into Sandra’s death, in my view there remains a risk that sepsis will go unrecognized , and urgent treatment will be delayed, putting patients attending Blackpool Victoria Hospital at risk. My duty to write this report is therefore met. It is not for me to be prescriptive about what action ought to be taken, but to raise this concern should I feel this is necessary.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a trust-wide sepsis quality-improvement collaborative and disseminate its change package through clinical teams.
Verbatim wording from the response “A new sepsis proforma was developed for clinical practice and the policy updated. Historically, the Trust had contributed to the AQUA audit for peer review and had a composite process score of around 30% and ranked below 12th position in the league tables within our area. The AQUA audit is of a small percentage of patients each quarter. This process was improved by increasing the number of audits to 40 patients per week, through the clinical audit team, with validated data. The Associate Directors. This more detailed audit provided the team with richer data which enabled the identification of learning themes and areas of targeted focus. The learning themes were used to design a quality improvement collaborative which began in May 22 for the management of patients with sepsis.” Source location Response from Blackpool Teaching Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Submit incidents for delayed sepsis identification, conduct rapid reviews where harm is suspected, and feed identified learning into the sepsis pathway group.
Verbatim wording from the response “I would like to assure you that if our records show that a patient’s sepsis has not been identified within the appropriate timescale, incidents are submitted on the Trust’s incident management system. Where harm is suspected the Trust undertakes a Rapid Review which is presented to the twice weekly Rapid Review Panel. This process ensures that appropriate learning is identified and a proportionate learning response deployed. Where learning is identified, this is fed into the Trust’s sepsis pathway group to enable further improvements to be initiated.” Source location Response from Blackpool Teaching Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver sepsis briefings, safety-huddle and team-meeting teaching, mandated recognition-and-action training, induction training and ward-level knowledge audits.
Verbatim wording from the response “To support staff knowledge, briefings for all staff were developed and shared through safety huddles, team meetings and training. This was supported by ward/ unit level ‘teach/learn’ audits whereby the ward managers/leaders ask staff questions related to sepsis each month and use the results to improve practice. For sustainability sepsis was included in the mandated recognition and act training for all clinical staff and inductions.” Source location Response from Blackpool Teaching Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Focus the next 12 months of quality-improvement work on escalation pathways through expert forums and trust-wide events.
Verbatim wording from the response “The Trust continues to keep sepsis in focus with monthly updates provided to the Trust’s Clinical Governance Committee, and Quality Assurance Committee regarding sepsis pathway compliance. The current area of focus for improvement are:” Source location Response from Blackpool Teaching Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an updated sepsis policy and clinical sepsis proforma aligned with national guidance and the sepsis six.
Verbatim wording from the response “A new sepsis proforma was developed for clinical practice and the policy updated. Historically, the Trust had contributed to the AQUA audit for peer review and had a composite process score of around 30% and ranked below 12th position in the league tables within our area. The AQUA audit is of a small percentage of patients each quarter. This process was improved by increasing the number of audits to 40 patients per week, through the clinical audit team, with validated data. The Associate Directors. This more detailed audit provided the team with richer data which enabled the identification of learning themes and areas of targeted focus. The learning themes were used to design a quality improvement collaborative which began in May 22 for the management of patients with sepsis.” Source location Response from Blackpool Teaching Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly Emergency Department sepsis review meetings to examine data and drive improvement.
Verbatim wording from the response “For areas with high numbers of sepsis patients, such as the Emergency Department (ED), a weekly review meeting was put in place and has continued to ensure focus on data and improvements. Overall compliance to the actions from the organisation are reviewed through a monthly subject matter expert group for sepsis, where the data, training, new ways of working are monitored.” Source location Response from Blackpool Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase validated sepsis pathway auditing to 40 patients weekly and use identified learning themes to target improvement.
Verbatim wording from the response “A new sepsis proforma was developed for clinical practice and the policy updated. Historically, the Trust had contributed to the AQUA audit for peer review and had a composite process score of around 30% and ranked below 12th position in the league tables within our area. The AQUA audit is of a small percentage of patients each quarter. This process was improved by increasing the number of audits to 40 patients per week, through the clinical audit team, with validated data. The Associate Directors. This more detailed audit provided the team with richer data which enabled the identification of learning themes and areas of targeted focus. The learning themes were used to design a quality improvement collaborative which began in May 22 for the management of patients with sepsis.” Source location Response from Blackpool Teaching Hospitals
Open published response
12 Apr 2024 Sabina Wood · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Lack of a standardized process for creating and completing discharge summaries View source Failure to prepare discharge summaries only when patients are ready for discharge View source Failure of the discharge-summary IT system to verify completion before marking documents complete View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sabina Wood · 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
Sabina Wood was admitted to hospital with abdominal pain, gallstones and possible bile duct stones, underwent an ERCP, and self-discharged against medical advice. She was found unresponsive at home on 27 January 2023 and her death was recorded as a natural death, with acute haemorrhagic pancreatitis and cholelithiasis stated as the medical cause. The principal concern was that a speculative and inaccurate draft discharge summary, prepared before the ERCP and sent to her GP practice, reflected unsafe processes and could pose a risk to future patients.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a standardized process for creating and completing discharge summaries
Wider context from the report “I heard extensive evidence on the practice of preparing hospital discharge summaries over the two days of the inquest.
I heard that doctors commonly start to prepare discharge documentation before a patient is ready for discharge. I found that this occurred across disciplines and hospitals given that ████████ now works at the Royal Preston Hospital as a Consultant where I heard the practice also takes place. The rationale explained to me was that discharge summaries were created early and worked on throughout patient stays. This was to save time and to prevent lengthy summaries being written at the end of long stays for patients. I heard from ████████, Head of General Internal Medicine at the Blackpool Victoria Hospital that each doctor’s practice is different and it is for individual doctors to decide how they create and complete discharge summaries . I found that there is no process or procedure for discharge summaries to be created prior to discharge taking place at the Blackpool Victoria Hospital .
In this case, ████████ created the document on 20th January 2023 before Sabina underwent the ERCP procedure. This document indicated that the patient was discharged on medical advice when in fact she self-discharged against medical advice. The section on ERCP was left blank intending to be completed after the procedure took place and set out that Sabina was well in herself upon discharge with pain settling. As the discharge summary was prepared prior to the ERCP taking place it could not be known whether Sabina was well in herself or that her pain was settling.
████████ mistakenly clicked on the completed button rather than the save button on 20th January 2023. There is no mechanism for the IT system to double check the document is completed before marking the document as complete. The draft discharge summary was sent by staff on 24th January 2023 after Sabina’s self-discharge on 23rd January 2023. Staff members believed that it was ready to be sent as it was marked complete by ████████.
████████ accepted in her evidence that a draft discharge summary was sent to Sabina’s GP Practice in error and told me that her revised practice is that she instructs her junior doctors to mark the discharge summaries as drafts.
I heard evidence that Blackpool Teaching Hospital NHS Foundation Trust are undertaking a review which hasn’t yet commenced. This will look at the development of a policy of how discharge summaries are prepared. This will also include a review of the IT system with regard to creating and completing discharge summaries.
I found it very concerning to hear that speculative information in Sabrina’s case was placed on the discharge summary before her procedure took place. There is a risk that this could occur again and in the future this may be significant for a patient’s treatment and care.
I found that the sending of a draft discharge summary to Sabina’s GP Practice by Blackpool Victoria Hospital didn’t contribute to Sabina’s death. I found that a correctly completed and finalised discharge summary wouldn’t have changed the steps taken by ████████ on 25th January 2023 who was told by the patient that she was improving. It is however, of vital importance that GPs receive timely and accurate discharge summaries from hospitals which may be significant in other cases.
For that reason and not notwithstanding the review or audit that is about to commence at the Blackpool Teaching Hospital NHS Foundation Trust, I consider my duty to prevent future deaths is triggered and that there is a risk to of deaths in the future from this practice which is commonplace and neither medical specialist or hospital specific.
I found that these matters gave rise to a risk of future deaths and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prepare discharge summaries only when patients are ready for discharge
Wider context from the report “I heard extensive evidence on the practice of preparing hospital discharge summaries over the two days of the inquest.
I heard that doctors commonly start to prepare discharge documentation before a patient is ready for discharge . I found that this occurred across disciplines and hospitals given that ████████ now works at the Royal Preston Hospital as a Consultant where I heard the practice also takes place. The rationale explained to me was that discharge summaries were created early and worked on throughout patient stays . This was to save time and to prevent lengthy summaries being written at the end of long stays for patients. I heard from ████████, Head of General Internal Medicine at the Blackpool Victoria Hospital that each doctor’s practice is different and it is for individual doctors to decide how they create and complete discharge summaries. I found that there is no process or procedure for discharge summaries to be created prior to discharge taking place at the Blackpool Victoria Hospital.
In this case, ████████ created the document on 20th January 2023 before Sabina underwent the ERCP procedure. This document indicated that the patient was discharged on medical advice when in fact she self-discharged against medical advice. The section on ERCP was left blank intending to be completed after the procedure took place and set out that Sabina was well in herself upon discharge with pain settling. As the discharge summary was prepared prior to the ERCP taking place it could not be known whether Sabina was well in herself or that her pain was settling .
████████ mistakenly clicked on the completed button rather than the save button on 20th January 2023. There is no mechanism for the IT system to double check the document is completed before marking the document as complete. The draft discharge summary was sent by staff on 24th January 2023 after Sabina’s self-discharge on 23rd January 2023. Staff members believed that it was ready to be sent as it was marked complete by ████████.
████████ accepted in her evidence that a draft discharge summary was sent to Sabina’s GP Practice in error and told me that her revised practice is that she instructs her junior doctors to mark the discharge summaries as drafts.
I heard evidence that Blackpool Teaching Hospital NHS Foundation Trust are undertaking a review which hasn’t yet commenced. This will look at the development of a policy of how discharge summaries are prepared. This will also include a review of the IT system with regard to creating and completing discharge summaries.
I found it very concerning to hear that speculative information in Sabrina’s case was placed on the discharge summary before her procedure took place. There is a risk that this could occur again and in the future this may be significant for a patient’s treatment and care.
I found that the sending of a draft discharge summary to Sabina’s GP Practice by Blackpool Victoria Hospital didn’t contribute to Sabina’s death. I found that a correctly completed and finalised discharge summary wouldn’t have changed the steps taken by ████████ on 25th January 2023 who was told by the patient that she was improving. It is however, of vital importance that GPs receive timely and accurate discharge summaries from hospitals which may be significant in other cases.
For that reason and not notwithstanding the review or audit that is about to commence at the Blackpool Teaching Hospital NHS Foundation Trust, I consider my duty to prevent future deaths is triggered and that there is a risk to of deaths in the future from this practice which is commonplace and neither medical specialist or hospital specific.
I found that these matters gave rise to a risk of future deaths and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the discharge-summary IT system to verify completion before marking documents complete
Wider context from the report “I heard extensive evidence on the practice of preparing hospital discharge summaries over the two days of the inquest.
I heard that doctors commonly start to prepare discharge documentation before a patient is ready for discharge. I found that this occurred across disciplines and hospitals given that ████████ now works at the Royal Preston Hospital as a Consultant where I heard the practice also takes place. The rationale explained to me was that discharge summaries were created early and worked on throughout patient stays. This was to save time and to prevent lengthy summaries being written at the end of long stays for patients. I heard from ████████, Head of General Internal Medicine at the Blackpool Victoria Hospital that each doctor’s practice is different and it is for individual doctors to decide how they create and complete discharge summaries. I found that there is no process or procedure for discharge summaries to be created prior to discharge taking place at the Blackpool Victoria Hospital.
In this case, ████████ created the document on 20th January 2023 before Sabina underwent the ERCP procedure. This document indicated that the patient was discharged on medical advice when in fact she self-discharged against medical advice. The section on ERCP was left blank intending to be completed after the procedure took place and set out that Sabina was well in herself upon discharge with pain settling. As the discharge summary was prepared prior to the ERCP taking place it could not be known whether Sabina was well in herself or that her pain was settling.
████████ mistakenly clicked on the completed button rather than the save button on 20th January 2023. There is no mechanism for the IT system to double check the document is completed before marking the document as complete . The draft discharge summary was sent by staff on 24th January 2023 after Sabina’s self-discharge on 23rd January 2023. Staff members believed that it was ready to be sent as it was marked complete by ████████.
████████ accepted in her evidence that a draft discharge summary was sent to Sabina’s GP Practice in error and told me that her revised practice is that she instructs her junior doctors to mark the discharge summaries as drafts.
I heard evidence that Blackpool Teaching Hospital NHS Foundation Trust are undertaking a review which hasn’t yet commenced. This will look at the development of a policy of how discharge summaries are prepared. This will also include a review of the IT system with regard to creating and completing discharge summaries.
I found it very concerning to hear that speculative information in Sabrina’s case was placed on the discharge summary before her procedure took place. There is a risk that this could occur again and in the future this may be significant for a patient’s treatment and care.
I found that the sending of a draft discharge summary to Sabina’s GP Practice by Blackpool Victoria Hospital didn’t contribute to Sabina’s death. I found that a correctly completed and finalised discharge summary wouldn’t have changed the steps taken by ████████ on 25th January 2023 who was told by the patient that she was improving. It is however, of vital importance that GPs receive timely and accurate discharge summaries from hospitals which may be significant in other cases.
For that reason and not notwithstanding the review or audit that is about to commence at the Blackpool Teaching Hospital NHS Foundation Trust, I consider my duty to prevent future deaths is triggered and that there is a risk to of deaths in the future from this practice which is commonplace and neither medical specialist or hospital specific.
I found that these matters gave rise to a risk of future deaths and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
” 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 Implement the integrated NPR eDischarge system with auto-population and password safeguards preventing incomplete discharge summaries from being issued.
Verbatim wording from the response “With regard to the IT system in place to provide discharge summaries, to which your concern relates, the Trust are in the process of replacing the current eDischarge product with one integrated system built upon the Trust’s Nexus NPR platform, developed in house by our Application Development Team.” Source location Response from Blackpool Teaching Hospitals
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 Issue a safety instruction directing staff to take care when pre-populating discharge summaries and avoid prejudging investigation results.
Verbatim wording from the response “In the interim whilst system implementation is brought to completion, the Executive Medical Director will issue a safety instruction to all staff regarding the population of discharge summaries, stating that they need to take care when pre-populating and that clinicians are not to prejudge any investigation results.” Source location Response from Blackpool Teaching Hospitals
Open published response
11 Jun 2023 Marlene McCabe · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 6 Failure to communicate material patient mental health information between healthcare providers View source Failure to prevent substance misuse references and assumptions from obscuring mental health diagnoses View source Lack of clinician understanding of how to make urgent referrals into the PIMHT View source Delays in assessing patients who may appear to be or are reported to be intoxicated View source Difficulty sharing information between service providers using different databases View source Inconsistent availability of access to mental health records across service providers 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
Marlene McCabe · 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
Marlene McCabe was unlawfully killed in her own home on 4 September 2019 after being struck repeatedly on the head and face with a doorstop, causing catastrophic injuries. The concerns included urgent mental-health referral processes, inconsistent access to and sharing of mental-health records, the risk of substance misuse obscuring mental-health diagnoses, non-communication of material information, and delayed assessment of apparently intoxicated patients.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate material patient mental health information between healthcare providers
Wider context from the report “4) There is a residual risk of non-communication of material information pertaining to patients’ mental health between healthcare providers .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent substance misuse references and assumptions from obscuring mental health diagnoses
Wider context from the report “3) There is a residual risk that reference to drug and/or alcohol misuse in mental health referrals and/or assessments may lead to the missing of a mental health diagnosis and that circumstances may arise in which assumptions are made concerning substance misuse .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician understanding of how to make urgent referrals into the PIMHT
Wider context from the report “1) There remains the potential for a lack of understanding amongst clinicians as to how urgent referrals into the PIMHT should be made .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in assessing patients who may appear to be or are reported to be intoxicated
Wider context from the report “5) There is a risk that delayed assessment of patients who may appear to be or are reported to be intoxicated will give rise to a loss of opportunity to identify signs of psychosis.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulty sharing information between service providers using different databases
Wider context from the report “2) There is inconsistent availability of access to mental health records across the service providers and information sharing between service providers using different data bases is 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent availability of access to mental health records across service providers
Wider context from the report “2) There is inconsistent availability of access to mental health records across the service providers and information sharing between service providers using different data bases is difficult.
” Open source report
17 Jun 2022 Margaret Florence Joyce Stringer · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Lack of a fail-safe, documented system preventing residents’ access to restricted items View source Failure to maintain a comprehensive, timely and accessible system for collating and transferring suicide-risk information between service providers View source Lack of staff training on the detrimental effects of isolation and loneliness in elderly people View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Florence Joyce Stringer · 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
Margaret Florence Joyce Stringer died by suicide between 18.35 and 19.00 on 10 October 2020 in the bathroom adjoining her room at Nightingales Nursing Home. The inquest found that appropriate precautions were not taken, including the return of an item used as a ligature, and that information about her suicide risk was incomplete and insufficiently recognised. Concerns included the absence of a fail-safe system to restrict access to dangerous items and weaknesses in the collation and transfer of information about suicide risk between services.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a fail-safe, documented system preventing residents’ access to restricted items
Wider context from the report “1) (Addressed to Nightingales Care Limited and Zion Care Limited, referred to collectively as ‘Nightingales’)
Whereas the court heard evidence that Nightingales would not accept another patient with an equivalent medical profile/history and that, should a resident within one of Nightingales’ homes require access to items to be restricted, they would be given 1:1 support pending a mental health assessment and discharge to a more appropriate facility, it was not possible for the home concerned to advise the court as to how and by whom the lead in question had been returned to Mrs Stringer . The concern arises that, in the case of a resident whose care requires access to items to be restricted, there should be a fail-safe, documented system, known to and implemented by staff, by which access to those items by the resident is prevented . In the circumstances that the possibility of a resident requiring such care may still arise, this concern exists notwithstanding the decisions now made.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a comprehensive, timely and accessible system for collating and transferring suicide-risk information between service providers
Wider context from the report “3) (Addressed to Lancashire and South Cumbria NHS Foundation Trust, Blackpool Teaching Hospitals NHS Foundation Trust, Lancashire County Council, Nightingales Care Limited and Zion Care Limited (the latter referred to collectively as ‘Nightingales’))
The court heard evidence and/or found that a number of steps had not been taken pertaining to the transfer of information concerning Mrs Stringer’s risk of suicide . They included the following:
i. The care coordinator should have requested that the acute hospital make a referral to the Mental Health Liaison Team for a review;
ii. It would have been good practice for a further professionals meeting / CPA review to have taken place prior to formal discharge and no later than just after discharge to Nightingales and for the family to have been invited, to ensure that everyone was aware of the plan, that the family was aware of Mrs Stringer’s legal status and to discuss next steps in terms of liaison with other services;
iii. There should have been greater professional curiosity and better communication at the time of transfer;
iv. The Harbour mental health hospital’s RNNA should have been reviewed to determine whether it needed to be updated and it should have been updated if there was any different clinical information. Further self harm or suicidal ideation, if seen to be significant, should have given rise to a further RNNA;
v. There had, in fact, been further indications of self harm and suicidal ideation and, in any event, of a wish to die, on 30th June 2020, in August 2020 and on 3rd September 2020 which were significant and should have been addressed in the information provided to Nightingales and had not been;
vi. Mrs Stringer was discharged from The Harbour mental health hospital without an up-to-date Care Act Assessment and, in any event, taking into account the need for Mrs Stringer to be transferred to the acute hospital (which had been necessary), an up-to-date Care Act Assessment had not been completed during the period of her admission to the latter hospital;
vii. The risk assessment should have been completed and provided to Nightingales;
viii. A positive behaviour support plan should have been completed and provided to Nightingales;
ix. A care plan, compliant with CPA Policy and Procedures Key Standard 10, which should have identified a suitable environment in which to manage Mrs Stringer’s risk, her needs and mental health and crisis and contingency planning, to cater for the event of a significant relapse in her mental health, should have been completed and provided to Nightingales;
x. Risk behaviour should have been identified to Nightingales and context given, whereas that had not been the case in respect of certain behaviour, including the incident on 30th June 2020;
xi. The care coordinator should have been better informed at the points of transfer and discharge;
xii. There should have been more robust follow up by the care coordinator whilst Mrs Stringer was at the acute hospital;
xiii. There had been no mental health service involvement between the 7-day follow up and 28th September 2020 or, if there had, it had not been recorded;
xiv. During the COVID-19 pandemic, it was not possible for a manager to carry out a face-to-face assessment in the mental health hospital but no equivalent measure had been implemented;
xv) Whereas it would have been helpful for Nightingales to have received the Continuing Healthcare Checklist, it had not been provided;
xvi) Nightingales would have wished to see the risk of suicide referred to in the “Risks to the Service User” section of the FACE Overview Assessment;
xvii) The court appointed expert had concerns about the accessibility of key information in the FACE Overview Assessment given the format of that document.
Whereas the court heard evidence concerning subsequent, significant, purposeful, developments in practice, the matters listed above can be condensed into a single concern that there should be a comprehensive, cohesive, frictionless system for the timely collation (including from the family and/or other carers) and timely communication / transfer of sufficient, accessible information ((not, simply, risk assessments) pertaining to suicide risk in patients / service users / residents, by and between each of the service providers concerned .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training on the detrimental effects of isolation and loneliness in elderly people
Wider context from the report “2) (Addressed to Nightingales Care Limited and Zion Care Limited, referred to collectively as ‘Nightingales’)
The court heard evidence as to the potential detrimental effects of isolation and loneliness in the elderly, including evidence from the court appointed expert that isolation can be very corrosive, that it is the single most potent causative risk factor for depression in the elderly and that it can have a very detrimental effect on a person’s mental state. There is a need for this to be known amongst staff . The concern arises as one member of staff gave (disputed) evidence that they had little or no training in such matters .
” 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 Cascade respective organisational expectations to matrons, ward managers and consultant groups, including requirements for communicating suicide-risk information.
Verbatim wording from the response “BTHFT will collaborate with LSCFT and LCC to examine this LSCFT policy, and the interface with Acute Trusts and Local Authorities. We will cascade to the Matron, ward manager and consultant groups, what is expected of the respective organisations; to ensure that all relevant information, including suicide risk, is known, managed and communicated.” Source location Response from Blackpool Teaching Hospitals
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 Hold a further meeting with LSCFT and LCC to consider continuity and safety of communication and information sharing.
Verbatim wording from the response “I, as BTHFT’s Executive Medical Director, together with the Clinical Lead for Discharge Services and Interim Head of Legal Services, have attended a meeting with LSCFT, to consider whether expectations are aligned for the continuity and safety of communication and information sharing between our organisations. A further meeting is proposed in September, to include LCC.” Source location Response from Blackpool Teaching Hospitals
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 Attend a cross-organisational meeting to consider alignment of communication and information-sharing expectations with LSCFT.
Verbatim wording from the response “I, as BTHFT’s Executive Medical Director, together with the Clinical Lead for Discharge Services and Interim Head of Legal Services, have attended a meeting with LSCFT, to consider whether expectations are aligned for the continuity and safety of communication and information sharing between our organisations. A further meeting is proposed in September, to include LCC.” Source location Response from Blackpool Teaching Hospitals
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 Collaborate with LSCFT and LCC to examine the transfer policy and its interface with acute trusts and local authorities.
Verbatim wording from the response “BTHFT has also been provided with a copy of a policy prepared by LSCFT; the Admission, Discharge and Transfer of Care Policy and Procedure, which provides LSCFT clinical staff with guidance on the admission, discharge, transfer and hand over of patients between wards, teams and services whether they are within LSCFT or other service/private providers.” Source location Response from Blackpool Teaching Hospitals
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 System or process changes for identifying suicide risk should originate with LSCFT and be cascaded to acute trusts and local authorities.
Verbatim wording from the response “BTHFT is one of many acute hospitals across this region which will interface with LSCFT for inter-hospital referrals and transfers. Similarly, it will interface with a number of local authorities who are making s.117 arrangements for patients previously admitted to LSCFT. LSCFT also provides a Mental Health Liaison Team service for BTHFT patients. The Trust respectfully submits that any system or process change for the sufficient identification of suicide risk should originate in LSCFT for their patients, to be cascaded and embedded with Acute Trusts and Local Authorities in the region.” Source location Response from Blackpool Teaching Hospitals
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 Local authorities and the Clinical Commissioning Group have primary responsibility for Mental Health Act section 117 aftercare arrangements.
Verbatim wording from the response “In relation to BTHFT’s internal process and protocol for the management of patients admitted from a mental health facility, and/or in relation to the Trust’s contribution to the Mental Health Act (MHA) s.117 aftercare arrangements (which are the primary responsibility of the local authority and Clinical Commissioning Group, there is nothing BTH would propose to change at this point. The expectation and standard practice is that in inter-hospital transfers, the transferring hospital should always provide the receiving hospital with key medical and mental health information, together with contact details for the referring clinician, for ongoing communication. The provided mental health information can then be included in the Registered Nursing Needs Assessment, in addition to the medical aspects, to feed into the MHA s.117 aftercare arrangements.” Source location Response from Blackpool Teaching Hospitals
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 BTHFT proposes no change to its internal processes because existing inter-hospital transfer practice requires sharing key medical and mental health information.
Verbatim wording from the response “In relation to BTHFT’s internal process and protocol for the management of patients admitted from a mental health facility, and/or in relation to the Trust’s contribution to the Mental Health Act (MHA) s.117 aftercare arrangements (which are the primary responsibility of the local authority and Clinical Commissioning Group, there is nothing BTH would propose to change at this point. The expectation and standard practice is that in inter-hospital transfers, the transferring hospital should always provide the receiving hospital with key medical and mental health information, together with contact details for the referring clinician, for ongoing communication. The provided mental health information can then be included in the Registered Nursing Needs Assessment, in addition to the medical aspects, to feed into the MHA s.117 aftercare arrangements.” Source location Response from Blackpool Teaching Hospitals
Open published response
11 May 2021 Coral Amy O’Donnell · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 7 Limited awareness among medical professionals of PVL-SA infection diagnosis and management guidance View source Insufficient microbiologist staffing capacity View source Lack of clinician awareness of relevant PVL guidance and hospital protocols View source Lack of awareness among primary and secondary care professionals of PVL-SA risk indicators View source Failure of critical care and microbiology teams to communicate relevant patient information View source Lack of clinician awareness and training in relevant internal information systems View source Failure of clinical and microbiology teams to consider PVL Staphylococcus Aureus when Staphylococcus Aureus is identified View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Coral Amy O’Donnell · 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
Coral Amy O’Donnell developed severe pneumonia after presenting with cough and cold-like symptoms and died in hospital on 17 May 2019 after prolonged intensive care. Concerns included failure to consider PVL Staphylococcus aureus promptly, limited awareness of relevant guidance and internal systems, problematic communication between critical care and microbiology teams, and insufficient microbiology staffing.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited awareness among medical professionals of PVL-SA infection diagnosis and management guidance
Wider context from the report “The court was told that there is a Public Health England publication entitled “Guidance on the diagnosis & management of PVL – associated Staphylococcus aureus infections”, but amongst medical professionals any awareness of this guidance appears to be limited .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient microbiologist staffing capacity
Wider context from the report “That the number of microbiologists at the time of Coral’s admission was limited – a senior Microbiologist told the court her team ought to comprise six microbiologists, but were limited to a maximum of four at the time and that remains 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician awareness of relevant PVL guidance and hospital protocols
Wider context from the report “That there was a lack of awareness of PVL amongst senior clinicians , despite the fact that a senior Microbiologist from the hospital Trust confirmed that national guidance covering the treatment of such condition was in use at the Trust at the time, but none of the critical care team who gave evidence at the inquest seem to have been aware of that document . Although the court was told this has now been rectified there is a concern that some clinicians are unfamiliar with hospital protocols which may be relevant to their work ;
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among primary and secondary care professionals of PVL-SA risk indicators
Wider context from the report “Although Staphylococcus aureus is a common bacterial infection, for the PVL strain of that infection to lead to the lung damage suffered by Coral is very rare. Nevertheless, one of the symptoms which may give medical professionals an indication that a patient may be at risk of PVL – SA is a history of skin infections and in otherwise healthy young people. There is clearly a lack of awareness of this condition in both primary and secondary care and in the absence of efforts to highlight this issue, young people such as Coral may continue to be placed 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of critical care and microbiology teams to communicate relevant patient information
Wider context from the report “That communication between the critical care and microbiology teams was problematic and neither team considered PVL until there was established damage to her lungs identified on a chest x-ray. Senior clinicians had not mentioned a susceptibility to skin infections to the microbiologists which may have resulted in Coral receiving the correct treatment at an early stage of admission. The lack of communication between Microbiology and the clinical team appears to have in part been contributed to by a previous cessation of the thrice weekly joint microbiology and critical care ward rounds, which the court heard have not been re-instated;
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician awareness and training in relevant internal information systems
Wider context from the report “That there was a stark lack of awareness, noticeably amongst senior clinicians, about internal systems in place at the hospital Trust . The Cyberlab system, and also a red flag system which the court was told a number of critical care clinicians had previously been unaware of . If clinicians have not received the necessary training in relation to such systems there is a risk they may not recognise potentially relevant information , placing patients at potential 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical and microbiology teams to consider PVL Staphylococcus Aureus when Staphylococcus Aureus is identified
Wider context from the report “That when evidence of Staphylococcus Aureus was identified the clinical and microbiology teams did not consider the possibility of Panton Valentine Leukocidin (PVL) Staphylococcus Aureus , despite Coral’s history of skin infections and the severe pneumonia she presented with on admission in a previously young fit woman.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a staffing review covering microbiologists and other infection-specialist roles.
Verbatim wording from the response “The Trust is undertaking a staffing review, which takes into consideration the role of infection specialists of various categories, not only microbiology trained medics, but also Microbiologists, Infectious Diseases Physicians, PhD grade Antibiotic Pharmacists and Clinical Scientists with or without FRCPath.” Source location 2021-0152-Response-from-Blackpool-Victoria-Hospital-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operationalise reinstatement of thrice-weekly joint Critical Care and Microbiology ward rounds.
Verbatim wording from the response “There are currently no joint ward rounds between the Critical Care Team and the Microbiology team, but there is better day to day communication and discussion at the Antimicrobial Stewardship Committee. At present, the day to day system is via telephone conversations with the Microbiology team, as and when required, plus the Critical Care Consultants will send e-referrals when they require Microbiology advice. However, we acknowledge that this falls short of what is ideal, and this needs to be improved. It has been highlighted that there is an objective to reinstate the three times a week joint ward round with the Consultant Microbiologist and Consultant Intensivist and the discussions to operationalise this are taking place. There are also imminent changes to the consultant staffing model that we believe will further improve matters.” Source location 2021-0152-Response-from-Blackpool-Victoria-Hospital-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue raising PVL awareness among colleagues and through local induction.
Verbatim wording from the response “We acknowledge that there was a lack of awareness and knowledge with regards to PVL amongst the Critical Care Consultants, for which we apologise. As part of the discussions within the department, the Trust PVL policy has been shared with all the Critical Care Consultants. The importance of this infection has been discussed at the departmental meetings. We can assure you that all the Critical Care Consultants are familiar with the Trust PVL document and we will continue to raise awareness amongst our colleagues and at local induction.” Source location 2021-0152-Response-from-Blackpool-Victoria-Hospital-Redacted
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 Ensure Critical Care Consultants consider PVL Staphylococcus aureus whenever Staphylococcus aureus is isolated, particularly when the clinical presentation supports PVL.
Verbatim wording from the response “Following discussion with the Microbiology team, we have ensured that the Critical Care Consultant team consider PVL Staphylococcus Aureus in all cases where Staphylococcus Aureus is isolated, particularly where the clinical picture supports such a diagnosis. As part of our learning, we have had a very low index for initiating triple therapy where patients’ presentation suggests PVL and this includes commencing Intravenous IgG in several patients. We are now confident that a similar situation in the Intensive Care Unit would not be repeated and that any cases discussed with microbiology where PVL was clinically likely, patients would be commenced on PVL cover from the start; we are now treating non-PVL MRSA/MSSA patients, as well as PVL patients, with extended PVL regimes.” Source location 2021-0152-Response-from-Blackpool-Victoria-Hospital-Redacted
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 Cyberlab training to new Consultants and junior doctors through Trust induction.
Verbatim wording from the response “We can only apologise that it has been highlighted that there was a lack of awareness with regards to the Cyberlab system and this is not acceptable. All Critical Care Consultants have now received the appropriate training relating to the ‘red flag’ system and how to access information. All new Consultants and junior doctors will receive Cyberlab training as part of their Trust induction. We will continue to raise awareness through education and training for all staff working on the unit to ensure that this does not recur.” Source location 2021-0152-Response-from-Blackpool-Victoria-Hospital-Redacted
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 Share PVL learning and the need to consider PVL with departmental clinical staff and at morbidity and mortality review.
Verbatim wording from the response “Firstly, I must apologise that we failed to consider or identify the possibility of Panton Valentine Leukocidin (PVL) Staphylococcus Aureus for Coral. The details and the outcome have been discussed within the team and department and we are truly sorry for what happened. It is clear from the Serious Incident review that there was a general lack of awareness of this rare and serious strain of Staphylococcus aureus within the Critical Care Consultant team. The report findings and the need to consider PVL has been shared with all the clinical staff within the department and also discussed at the Morbidity and Mortality” Source location 2021-0152-Response-from-Blackpool-Victoria-Hospital-Redacted
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 raising awareness of Cyberlab and related systems through education and training for staff working on the unit.
Verbatim wording from the response “We can only apologise that it has been highlighted that there was a lack of awareness with regards to the Cyberlab system and this is not acceptable. All Critical Care Consultants have now received the appropriate training relating to the ‘red flag’ system and how to access information. All new Consultants and junior doctors will receive Cyberlab training as part of their Trust induction. We will continue to raise awareness through education and training for all staff working on the unit to ensure that this does not recur.” Source location 2021-0152-Response-from-Blackpool-Victoria-Hospital-Redacted
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 Share the Trust PVL policy with Critical Care Consultants and discuss the infection's importance at departmental meetings.
Verbatim wording from the response “We acknowledge that there was a lack of awareness and knowledge with regards to PVL amongst the Critical Care Consultants, for which we apologise. As part of the discussions within the department, the Trust PVL policy has been shared with all the Critical Care Consultants. The importance of this infection has been discussed at the departmental meetings. We can assure you that all the Critical Care Consultants are familiar with the Trust PVL document and we will continue to raise awareness amongst our colleagues and at local induction.” Source location 2021-0152-Response-from-Blackpool-Victoria-Hospital-Redacted
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 Train all Critical Care Consultants to use the red-flag system and access its information.
Verbatim wording from the response “We can only apologise that it has been highlighted that there was a lack of awareness with regards to the Cyberlab system and this is not acceptable. All Critical Care Consultants have now received the appropriate training relating to the ‘red flag’ system and how to access information. All new Consultants and junior doctors will receive Cyberlab training as part of their Trust induction. We will continue to raise awareness through education and training for all staff working on the unit to ensure that this does not recur.” Source location 2021-0152-Response-from-Blackpool-Victoria-Hospital-Redacted
Open published response
Concerns raised 4 Fitting or adjustment of bed levers in the absence of the patient View source Lack of a policy for reporting bed-lever risk-assessment concerns to the Occupational Therapy Team View source Failure to ensure prescribed bed levers are fitted by trained Occupational Therapy staff View source Failure to ensure bed levers fitted to Divan beds use a strap 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
Jean Williams · 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
Jean Williams, aged 80, died at Thornton House Care Home between 6.30 a.m. and 8.27 a.m. on 19 November 2017 after her head became trapped between her bed and a chest of drawers, with her neck resting on a bed lever. The report found that the bed lever’s securing strap had not been used. Concerns included bed levers being fitted or adjusted without the patient present, insufficient reporting and training arrangements, and the possible supply or fitting of bed levers without the required strap.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Fitting or adjustment of bed levers in the absence of the patient
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them.
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy for reporting bed-lever risk-assessment concerns to the Occupational Therapy Team
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them.
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure prescribed bed levers are fitted by trained Occupational Therapy staff
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House . Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them .
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure bed levers fitted to Divan beds use a strap
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them.
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” 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 Implement prescriber-led bed-lever provision at Thornton House, requiring individual risk assessment, prescriber fitting, and an in-person checker visit.
Verbatim wording from the response “a) Bed levers are permitted for use at Thornton House. An individual risk assessment must be completed by the prescriber for each patient, in line with Blackpool Teaching Hospital’s cross-prescriber training.” Source location 2020-0239-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
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 Train Occupational Therapists to assess patients and correctly fit bed levers.
Verbatim wording from the response “2) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.” Source location 2020-0239-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
Open published response
19 Oct 2020 Douglas OWENS · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 8 Failure to record the actual medication dose given View source Failure to provide on-call specialist review in the Emergency Department when needed View source Failure to follow the review process after a marked blood pressure drop View source Failure to take vital signs observations View source Failure to record vital signs observations in the observation chart View source Failure to formalise urgent ophthalmic patient transfer arrangements View source Failure to complete prescription and fluid balance charts for prescribed fluids View source Failure of the Once-only and Pre-medication Chart to provide for recording the actual dose when a dose range is prescribed 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
Douglas OWENS · 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
Douglas Robert Owens developed acute cardiac failure, hypotension, aspiration pneumonia and multi-organ failure after cataract surgery, treatment for raised intraocular pressure, ongoing eye pain and painful urinary retention. He died in intensive care on 7 July 2018. Concerns included arrangements for urgent ophthalmic transfer, specialist assessment, monitoring and review of deterioration, fluid documentation, and recording medication doses.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the actual medication dose given
Wider context from the report “(6)That the evidence disclosed the fact that the Once-only and Pre-medication Chart does not make provision for the dose of medication actually given to be recorded in the event that the dose prescribed has been specified as falling within a range (for example, as here, morphine 1-10mg) and that, in any event, the actual dose given was not recorded in that chart . Unless the giving of medication is recorded fully the lives of patients may be put 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide on-call specialist review in the Emergency Department when needed
Wider context from the report “(2) That the Deceased was not seen by a speciality doctor in the Emergency Department notwithstanding the need for him to be seen. Unless action is taken there may be a continuing risk that patients in the Emergency Department will not be seen by on call doctors in speciality disciplines, in particular, ophthalmology, even when the need arises in that 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the review process after a marked blood pressure drop
Wider context from the report “(4)That the evidence disclosed that the review process was not followed upon the Deceased’s blood pressure dropping by more than 40mmHg , notwithstanding the fact that observation had been recorded. Unless action is taken, there is a risk that any deterioration in the condition of patients which might put their lives at risk will not be reviewed at the earliest opportunity.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to take vital signs observations
Wider context from the report “(3)That the evidence disclosed omissions in the taking of vital signs observations and in the recording of observations in the vital signs observation chart (incorporating the National Early Warning Score). Unless action is taken, there is a risk that any deterioration in the condition of patients which might put their lives at risk will not be identified at the earliest opportunity.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record vital signs observations in the observation chart
Wider context from the report “(3)That the evidence disclosed omissions in the taking of vital signs observations and in the recording of observations in the vital signs observation chart (incorporating the National Early Warning Score). Unless action is taken, there is a risk that any deterioration in the condition of patients which might put their lives at risk will not be identified at the earliest opportunity.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formalise urgent ophthalmic patient transfer arrangements
Wider context from the report “(1) That Blackpool Victoria Hospital has not yet finalised an agreement with Spire Fylde Coast Hospital for the urgent transfer of patients to the Ophthalmic Unit at Blackpool Victoria Hospital when appropriate . Unless arrangements are formalised, the lives of patients may be put 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete prescription and fluid balance charts for prescribed fluids
Wider context from the report “(5)That the evidence disclosed the fact that, whilst fluids had been prescribed, no prescription chart or fluid balance chart had been completed . Unless action is taken to ensure the completion of applicable documentation, the lives of patients may be put 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Once-only and Pre-medication Chart to provide for recording the actual dose when a dose range is prescribed
Wider context from the report “(6)That the evidence disclosed the fact that the Once-only and Pre-medication Chart does not make provision for the dose of medication actually given to be recorded in the event that the dose prescribed has been specified as falling within a range (for example, as here, morphine 1-10mg) and that, in any event, the actual dose given was not recorded in that chart. Unless the giving of medication is recorded fully the lives of patients may be put at risk.
” 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 Monitor NEWS2 chart completion through ward-level spot audits, immediate gap management and shared-learning governance discussions.
Verbatim wording from the response “Furthermore, the Trust monitors completion of the NEWS2 charts through spot audits undertaken by the Matrons and Ward Managers, with any gaps identified managed immediately at ward level and key themes are discussed at Nursing Quality Governance Meetings, with actions created for shared learning.” Source location 2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
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 Establish the Deteriorating Patient Collaborative to test safer recognition and response to clinical deterioration.
Verbatim wording from the response “At an organisational level, the Quality Improvement Strategy describes a new Deteriorating Patient Collaborative, to test ways of working that will help teams to recognise and respond to the clinical deterioration of patients and reduce preventable deaths. A Project Initiation Document has been prepared and a Senior Responsible Officer and Improvement Programme Manager have been identified to support the work. The Board of Directors support commencement of the Deteriorating Patient Collaborative and agreed to receive regular updates on progress as part of the Quality Improvement Strategy reporting mechanism.” Source location 2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
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 variable medication doses to be recorded in the PRN chart and monitor compliance through the Emergency Department pharmacist.
Verbatim wording from the response “The once only and pre-medication sections of the chart are to be used for STAT doses only where the exact dose to be given is clearly indicated. Variable doses are written on the PRN section of the chart with the person administering the medication completing the dose given. This is standard practice throughout the hospital and the ED have been reminded of this. The ED pharmacist will monitor to ensure this happens.” Source location 2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
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 Deliver deteriorating-patient simulation training for Emergency Department staff using Trust pathways and NEWS2 escalation algorithms.
Verbatim wording from the response “Over recent months, the Trust and the Emergency Department (ED) have committed to major improvement projects and programmes to improve the ‘recognise and act’ element in the care and treatment of a deteriorating patient. The ED currently are 92.91% compliant with the Trust’s Recognise and Act Mandatory Training (120 staff are compliant, nine staff are waiting to attend, three of which are new staff and two are paediatric nurses). We have a plan for all outstanding staff to attend the training, although limited places are available due to social distancing. Our two Advanced Clinical Practitioner’s (ACPs) are running simulation training sessions for all staff to attend, following the Trust Pathways of the recognition of the deteriorating patient. Both ACPs are Advanced Life Support (ALS) trainers and follow the ALS algorithms and the NEWS 2 Escalator.” Source location 2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
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 Conduct regular Emergency Department spot audits and huddles to verify NEWS2 recording, prompt escalation and completion of fluid charts.
Verbatim wording from the response “In the interim, the Head of the Emergency Department and the Matron will ensure senior clinical staff will undertake regular spot audits / huddles, to ensure all patients in the ED have their NEWS2 score recorded correctly, that any changes in score are acted upon promptly and that fluid charts are completed correctly and acted upon promptly. The ED complete a Consistency in Care Audit daily, where 40 patients’ notes (approximately 20% of all patients daily) are reviewed in real time and this includes a review of the NEWS 2 and fluid balance. This is used to monitor the compliance and manage any inconsistencies in care at the time. Additionally the ED undertakes an intentional round, where all patients who have been in the department for longer than 4 hours, are reviewed by the EPIC (Emergency Physician in Charge) to ensure that appropriate plans of care are in place.” Source location 2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
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 Develop and implement an ophthalmology emergency protocol covering handover, internal patient pathways and specialty attendance in the Emergency Department.
Verbatim wording from the response “The matter of an agreement with Spire Fylde Coast Hospital for the urgent transfer of patients to the Ophthalmic Unit at Blackpool Victoria Hospital has been considered and discussed at length with relevant consultant colleagues. After much deliberation, it was felt that an agreement with Spire Fylde Coast Hospital may not be sufficient to prevent similar incidents from occurring and thus the focus was directed to the development of more responsive and effective protocols in our existing services, to ensure that handover from Spire Fylde Coast Hospital to the Emergency Department (ED) and then ophthalmology would be performed quickly and comprehensively.” Source location 2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
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 Complete daily real-time Consistency in Care Audits reviewing NEWS2 and fluid-balance compliance and manage identified inconsistencies.
Verbatim wording from the response “In the interim, the Head of the Emergency Department and the Matron will ensure senior clinical staff will undertake regular spot audits / huddles, to ensure all patients in the ED have their NEWS2 score recorded correctly, that any changes in score are acted upon promptly and that fluid charts are completed correctly and acted upon promptly. The ED complete a Consistency in Care Audit daily, where 40 patients’ notes (approximately 20% of all patients daily) are reviewed in real time and this includes a review of the NEWS 2 and fluid balance. This is used to monitor the compliance and manage any inconsistencies in care at the time. Additionally the ED undertakes an intentional round, where all patients who have been in the department for longer than 4 hours, are reviewed by the EPIC (Emergency Physician in Charge) to ensure that appropriate plans of care are in place.” Source location 2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
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 A formal urgent-transfer agreement may not prevent similar incidents, so the concern is addressed through responsive protocols within existing services.
Verbatim wording from the response “The matter of an agreement with Spire Fylde Coast Hospital for the urgent transfer of patients to the Ophthalmic Unit at Blackpool Victoria Hospital has been considered and discussed at length with relevant consultant colleagues. After much deliberation, it was felt that an agreement with Spire Fylde Coast Hospital may not be sufficient to prevent similar incidents from occurring and thus the focus was directed to the development of more responsive and effective protocols in our existing services, to ensure that handover from Spire Fylde Coast Hospital to the Emergency Department (ED) and then ophthalmology would be performed quickly and comprehensively.” Source location 2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
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 Variable medication doses are recorded in the PRN section rather than the once-only chart, reflecting standard hospital practice.
Verbatim wording from the response “The once only and pre-medication sections of the chart are to be used for STAT doses only where the exact dose to be given is clearly indicated. Variable doses are written on the PRN section of the chart with the person administering the medication completing the dose given. This is standard practice throughout the hospital and the ED have been reminded of this. The ED pharmacist will monitor to ensure this happens.” Source location 2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
Open published response
20 Dec 2019 Matthew James Rogers · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Failure to monitor observations hourly for patients with a NEWS score greater than 5 View source Insufficient nurse staffing for the night shift View source Lack of processes to address omissions of care arising from understaffing 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
Matthew James Rogers · 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
Matthew James Rogers, aged 31, was admitted to hospital with worsening pain, weakness and lethargy and subsequently developed multiple organ injury before dying on 11 July 2019. His observations were not recorded for two and a half hours despite a NEWS score above 5, amid staffing levels below the planned establishment. The investigation report did not explain how the Trust intended to address omissions of care arising from understaffing.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor observations hourly for patients with a NEWS score greater than 5
Wider context from the report “The Serious Incident Investigation Report set out that the patient's observations were not monitored on an hourly basis in accordance with the Royal College of Physician's guidance for frequency of observations for a patient with a NEWS score of greater than 5 . It was noted in the report that Mr Rogers did not have a set of observations recorded for two and a half hours from 03:30 to 06:00 . Whilst it was not clear why this omission in care occurred, it was felt likely that this occurred because of understaffing of nurses compounded by the large number of patients within the department.
It was reported to me that the nurse staff levels were below template for the night shift. The staffing establishment was for 10 Registered Nurses. At the time in question six substantive Registered Nurses were on duty, plus one agency Emergency Department Registered Nurse. There were no Twilight Nurses or Long Day Registered Nurses.
The Serious Incident Investigation Report did not address how these problems were proposed to be resolved by the Trust and what processes were being put in place to address the issue of omission of care arising from understaffing.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient nurse staffing for the night shift
Wider context from the report “The Serious Incident Investigation Report set out that the patient's observations were not monitored on an hourly basis in accordance with the Royal College of Physician's guidance for frequency of observations for a patient with a NEWS score of greater than 5. It was noted in the report that Mr Rogers did not have a set of observations recorded for two and a half hours from 03:30 to 06:00. Whilst it was not clear why this omission in care occurred, it was felt likely that this occurred because of understaffing of nurses compounded by the large number of patients within the department.
It was reported to me that the nurse staff levels were below template for the night shift . The staffing establishment was for 10 Registered Nurses . At the time in question six substantive Registered Nurses were on duty, plus one agency Emergency Department Registered Nurse . There were no Twilight Nurses or Long Day Registered Nurses .
The Serious Incident Investigation Report did not address how these problems were proposed to be resolved by the Trust and what processes were being put in place to address the issue of omission of care arising from understaffing.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of processes to address omissions of care arising from understaffing
Wider context from the report “The Serious Incident Investigation Report set out that the patient's observations were not monitored on an hourly basis in accordance with the Royal College of Physician's guidance for frequency of observations for a patient with a NEWS score of greater than 5. It was noted in the report that Mr Rogers did not have a set of observations recorded for two and a half hours from 03:30 to 06:00. Whilst it was not clear why this omission in care occurred, it was felt likely that this occurred because of understaffing of nurses compounded by the large number of patients within the department.
It was reported to me that the nurse staff levels were below template for the night shift. The staffing establishment was for 10 Registered Nurses. At the time in question six substantive Registered Nurses were on duty, plus one agency Emergency Department Registered Nurse. There were no Twilight Nurses or Long Day Registered Nurses.
The Serious Incident Investigation Report did not address how these problems were proposed to be resolved by the Trust and what processes were being put in place to address the issue of omission of care arising from understaffing .
” Open source report
27 Jun 2019 Frank Raymond STOCKTON · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Lack of clinician awareness that maintaining a target Internationalised Normalised Ratio does not eliminate the risk of death View source Lack of clinician awareness of the fatal risks of epistaxis in patients receiving oxygen therapy, taking Warfarin, or with impaired lung or heart function View source Failure to identify the significance of references to nosebleeds in clinical records 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
Frank Raymond STOCKTON · 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
Frank Raymond Stockton was admitted to hospital with shortness of breath and collapse, later experienced recurrent nosebleeds while receiving oxygen therapy and Warfarin, and died on 22 July 2018 after developing melena and haematemesis. The principal concern was that the risks of epistaxis causing or contributing to death, particularly in patients receiving oxygen therapy or Warfarin or with impaired lung or heart function, may not be generally recognised by clinicians, and that maintaining the INR within its target range may not prevent this risk.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician awareness that maintaining a target Internationalised Normalised Ratio does not eliminate the risk of death
Wider context from the report “(1) It was the evidence of a number of clinicians who gave evidence in the course of the inquest that they had not come across a death occasioned by epistaxis in the course of their clinical careers. In those circumstances the cause of the deceased’s death may have been unusual. In that regard he received oxygen therapy both in hospital and, following discharge, at home through a nasal cannula and was also prescribed Warfarin on account of his atrial fibrillation. Whilst, for much of the period in question his Internationalised Normalised Ratio fell within the target range of 2.0 – 3.0 he developed epistaxis which, in the context of and in combination with compromised lung and heart function due to pulmonary fibrosis and ischaemic heart disease, caused his death. In the course of preparing statements for the purpose of the inquest 2 practitioners did not identify and/or did not identify the significance of 2 references to nosebleeds (epistaxis) (or the possibility thereof) within the clinical records.
Thus the concern arises that (1) the risks of epistaxis causing or contributing to death, particularly in a patient who is receiving oxygen therapy and/or who is taking Warfarin and/or who has underlying conditions which impair lung and/or heart function and (2) the fact that the risk of death may not be avoided merely on account of the maintenance of a patient’s Internationalised Normalised Ratio within a target range may not be known generally amongst clinicians such that circumstances creating a risk of other deaths will occur or will continue to exist in the future.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician awareness of the fatal risks of epistaxis in patients receiving oxygen therapy, taking Warfarin, or with impaired lung or heart function
Wider context from the report “(1) It was the evidence of a number of clinicians who gave evidence in the course of the inquest that they had not come across a death occasioned by epistaxis in the course of their clinical careers. In those circumstances the cause of the deceased’s death may have been unusual. In that regard he received oxygen therapy both in hospital and, following discharge, at home through a nasal cannula and was also prescribed Warfarin on account of his atrial fibrillation. Whilst, for much of the period in question his Internationalised Normalised Ratio fell within the target range of 2.0 – 3.0 he developed epistaxis which, in the context of and in combination with compromised lung and heart function due to pulmonary fibrosis and ischaemic heart disease, caused his death. In the course of preparing statements for the purpose of the inquest 2 practitioners did not identify and/or did not identify the significance of 2 references to nosebleeds (epistaxis) (or the possibility thereof) within the clinical records.
Thus the concern arises that (1) the risks of epistaxis causing or contributing to death, particularly in a patient who is receiving oxygen therapy and/or who is taking Warfarin and/or who has underlying conditions which impair lung and/or heart function and (2) the fact that the risk of death may not be avoided merely on account of the maintenance of a patient’s Internationalised Normalised Ratio within a target range may not be known generally amongst clinicians such that circumstances creating a risk of other deaths will occur or will continue to exist in the future.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the significance of references to nosebleeds in clinical records
Wider context from the report “(1) It was the evidence of a number of clinicians who gave evidence in the course of the inquest that they had not come across a death occasioned by epistaxis in the course of their clinical careers. In those circumstances the cause of the deceased’s death may have been unusual. In that regard he received oxygen therapy both in hospital and, following discharge, at home through a nasal cannula and was also prescribed Warfarin on account of his atrial fibrillation. Whilst, for much of the period in question his Internationalised Normalised Ratio fell within the target range of 2.0 – 3.0 he developed epistaxis which, in the context of and in combination with compromised lung and heart function due to pulmonary fibrosis and ischaemic heart disease, caused his death. In the course of preparing statements for the purpose of the inquest 2 practitioners did not identify and/or did not identify the significance of 2 references to nosebleeds (epistaxis) (or the possibility thereof) within the clinical records .
Thus the concern arises that (1) the risks of epistaxis causing or contributing to death, particularly in a patient who is receiving oxygen therapy and/or who is taking Warfarin and/or who has underlying conditions which impair lung and/or heart function and (2) the fact that the risk of death may not be avoided merely on account of the maintenance of a patient’s Internationalised Normalised Ratio within a target range may not be known generally amongst clinicians such that circumstances creating a risk of other deaths will occur or will continue to exist in the future.
” Open source report
1 May 2019 James David FLETCHER · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 10 Lack of staff knowledge about post-operative PEG risks and contraindications View source Failure to ensure peritonitis risk is identifiable after PEG surgery View source Failure to make timely clinical records communicating patients’ condition and care View source Loss or inaccessibility of records material to ongoing patient care View source Failure of internal serious incident investigations to identify PEG contraindications View source Failure to maintain records of sufficient quality for learning from investigations View source Lack of disseminated communication guidance and protocols for patients unable to communicate verbally View source Failure to ensure accurate and understood communication between clinical staff View source Failure to ensure essential medication is available in the correct location View source Failure to place required PEG warning labels in patient notes View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James David FLETCHER · 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
James David Fletcher died in hospital on 14 July 2018 following peritonitis caused by leakage of gastric contents after PEG tube insertion. The report identifies concerns including failure to consider or detect peritonitis, continued use of the PEG tube despite it being contraindicated, inadequate communication and record keeping, insufficient awareness of post-operative PEG risks, and difficulties ensuring essential medication was available.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge about post-operative PEG risks and contraindications
Wider context from the report “4) I am concerned that there is a lack of knowledge amongst medical and nursing staff who may come into contact with and have the responsibility for the care of patients who have undergone PEG surgery about the post-operative risks of such surgery, in particular the risk of peritonitis , of the signs and symptoms which may give rise to a differential diagnosis of peritonitis and of measures which would be or may be contraindicated in the circumstances that complications, including peritonitis develop. This is illustrated in the present case by an apparent lack of awareness that peritonitis may develop and that the use of the PEG tube in the circumstances concerned was contraindicated and by the omission to place a warning label in the Deceased’s notes as provided for by the applicable protocol. The fact that the use of the PEG tube was contraindicated was not identified in the course of the internal serious incident investigation.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure peritonitis risk is identifiable after PEG surgery
Wider context from the report “5) Related to 4) above I am concerned that the risk of peritonitis may have been shrouded by the identified risks of sepsis and of aspiration pneumonia and that the risk of peritonitis also needs to be identifiable by those providing care for patients following such surgery .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely clinical records communicating patients’ condition and care
Wider context from the report “2) There is a risk of future deaths because both patient care and the opportunity to learn valuable lessons following a death may be compromised by issues pertaining to the quality of record keeping and to the retention of records.
Whilst it is understood that “NEWS 2” is being introduced and supersedes the early warning score system being used at the time of the Deceased’s death and whilst the early warning score system in use at the time does not, therefore, form the subject matter of this report:
a) I am concerned that the evidence revealed that substantial periods of time elapsed, at times measuring 9 or more hours, when no entry was made in the Deceased’s History Sheet, notwithstanding the deteriorating nature of the Deceased’s condition . This approach to record keeping carries the risk of material information concerning the condition and care of patients not being communicated between medical, nursing and other clinicians ;
b) Complete records were not provided to the Court in accordance with directions given prior to the inquest. It was understood from the Trust that complete records were unavailable and yet it transpired on the first day of the inquest that further records were available but had not been found and produced previously. I am concerned that the system of record keeping gives rise to a risk that patients’ records which are material to their ongoing care will be lost or otherwise inaccessible.
c) I am concerned that, without records of appropriate quality being made and retained, the opportunity to learn lessons through the process of internal investigations and, should it arise, the Coroner investigation and inquest process will be compromised.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Loss or inaccessibility of records material to ongoing patient care
Wider context from the report “2) There is a risk of future deaths because both patient care and the opportunity to learn valuable lessons following a death may be compromised by issues pertaining to the quality of record keeping and to the retention of records.
Whilst it is understood that “NEWS 2” is being introduced and supersedes the early warning score system being used at the time of the Deceased’s death and whilst the early warning score system in use at the time does not, therefore, form the subject matter of this report:
a) I am concerned that the evidence revealed that substantial periods of time elapsed, at times measuring 9 or more hours, when no entry was made in the Deceased’s History Sheet, notwithstanding the deteriorating nature of the Deceased’s condition. This approach to record keeping carries the risk of material information concerning the condition and care of patients not being communicated between medical, nursing and other clinicians;
b) Complete records were not provided to the Court in accordance with directions given prior to the inquest. It was understood from the Trust that complete records were unavailable and yet it transpired on the first day of the inquest that further records were available but had not been found and produced previously. I am concerned that the system of record keeping gives rise to a risk that patients’ records which are material to their ongoing care will be lost or otherwise inaccessible .
c) I am concerned that, without records of appropriate quality being made and retained, the opportunity to learn lessons through the process of internal investigations and, should it arise, the Coroner investigation and inquest process will be compromised.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of internal serious incident investigations to identify PEG contraindications
Wider context from the report “4) I am concerned that there is a lack of knowledge amongst medical and nursing staff who may come into contact with and have the responsibility for the care of patients who have undergone PEG surgery about the post-operative risks of such surgery, in particular the risk of peritonitis, of the signs and symptoms which may give rise to a differential diagnosis of peritonitis and of measures which would be or may be contraindicated in the circumstances that complications, including peritonitis develop. This is illustrated in the present case by an apparent lack of awareness that peritonitis may develop and that the use of the PEG tube in the circumstances concerned was contraindicated and by the omission to place a warning label in the Deceased’s notes as provided for by the applicable protocol. The fact that the use of the PEG tube was contraindicated was not identified in the course of the internal serious incident investigation .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain records of sufficient quality for learning from investigations
Wider context from the report “2) There is a risk of future deaths because both patient care and the opportunity to learn valuable lessons following a death may be compromised by issues pertaining to the quality of record keeping and to the retention of records.
Whilst it is understood that “NEWS 2” is being introduced and supersedes the early warning score system being used at the time of the Deceased’s death and whilst the early warning score system in use at the time does not, therefore, form the subject matter of this report:
a) I am concerned that the evidence revealed that substantial periods of time elapsed, at times measuring 9 or more hours, when no entry was made in the Deceased’s History Sheet, notwithstanding the deteriorating nature of the Deceased’s condition. This approach to record keeping carries the risk of material information concerning the condition and care of patients not being communicated between medical, nursing and other clinicians;
b) Complete records were not provided to the Court in accordance with directions given prior to the inquest. It was understood from the Trust that complete records were unavailable and yet it transpired on the first day of the inquest that further records were available but had not been found and produced previously. I am concerned that the system of record keeping gives rise to a risk that patients’ records which are material to their ongoing care will be lost or otherwise inaccessible.
c) I am concerned that, without records of appropriate quality being made and retained, the opportunity to learn lessons through the process of internal investigations and, should it arise, the Coroner investigation and inquest process will be compromised .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of disseminated communication guidance and protocols for patients unable to communicate verbally
Wider context from the report “1) I am concerned that, whilst there exist policies concerned with the provision of care to those patients with learning disabilities there may be a lack of disseminated guidance and protocols for the care of those patients who are unable to communicate verbally . It is of particular concern that, in such cases, measures should be identified by which a method of communication can be established and/or appropriate measures should be put in place to compensate for any lack of communication verbally , including but not necessarily limited to the use of objective observations.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate and understood communication between clinical staff
Wider context from the report “3) I am concerned that communications between medical staff, between nursing staff and between medical and nursing staff should be accurate and that it should be ensured that they have been understood . By way of example, in this matter, there was either miscommunication or misunderstanding of the position concerning the taking of an abdominal x-ray and an apparent miscommunication or misunderstanding of the level of expertise being offered in the interpretation of a chest x-ray.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure essential medication is available in the correct location
Wider context from the report “6) The evidence disclosed that certain essential medication had not been retained in close proximity to the Deceased, where it was required . I am concerned that, in such circumstances, essential medication may be required urgently to protect the life of a patient and that systems should be robust enough to ensure that it is available in the correct location .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to place required PEG warning labels in patient notes
Wider context from the report “4) I am concerned that there is a lack of knowledge amongst medical and nursing staff who may come into contact with and have the responsibility for the care of patients who have undergone PEG surgery about the post-operative risks of such surgery, in particular the risk of peritonitis, of the signs and symptoms which may give rise to a differential diagnosis of peritonitis and of measures which would be or may be contraindicated in the circumstances that complications, including peritonitis develop. This is illustrated in the present case by an apparent lack of awareness that peritonitis may develop and that the use of the PEG tube in the circumstances concerned was contraindicated and by the omission to place a warning label in the Deceased’s notes as provided for by the applicable protocol . The fact that the use of the PEG tube was contraindicated was not identified in the course of the internal serious incident investigation.
” 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 Use the SBAR tool to communicate important clinical information during transfers and patient reviews.
Verbatim wording from the response “3) Accuracy of communication between medical and nursing staff – The Trust recently introduced a revised early warning score NEWS2 which is a national programme for the recognition of patients who require assessment. There has been a training programme overseen by the Interim Director of Quality Improvement and the Deputy Medical Director to ensure that all staff are aware of this. The above two officers jointly chair the Care of the Acutely Ill Patient workstream within the Trust and have oversight of the roll-out of the training programme. In addition the Trust has a SBAR tool to convey important information between clinicians when patients are being transferred from one area to another when review of a patient is required.” Source location 2019-0146-Response-by-Blackpool-Teaching-Hospitals-NHS-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 Develop a revised Electronic Document Management System business case for Executive Director consideration.
Verbatim wording from the response “2) Concern regarding record keeping – Whilst the Trust has made progress with electronic access to general practice records and partial provision of electronic records within the Emergency Department we have not as yet implemented an Electronic Document Management System (EDMS). A business case was approved by the Trust Board in January 2018 but because of more pressing cost pressures it has not been possible to progress this to date. A revised business case is in development and due for consideration by Executive Directors by the end of this month.” Source location 2019-0146-Response-by-Blackpool-Teaching-Hospitals-NHS-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 Issue a staff Red Alert reinforcing vigilance for post-operative peritonitis and guidance on PEG-tube care.
Verbatim wording from the response “4) A lack of knowledge about risks of peritonitis in patients who have undergone PEG surgery - As identified in the Serious Incident (SI) investigation report signed off by the Chief Executive in December of last year a death after PEG tube insertion is rare and occurs in less than 1% of procedures and peritonitis too is a rare complication. That notwithstanding, staff should be alert to the risk of peritonitis in any patient who has undergone abdominal surgery and I have issued a Red Alert to all staff in the light of this serious incident investigation to remind them of: vigilance in the post-operative period and of the need to be alert to the possibility of peritonitis; and guidelines on the care of PEG tubes.” Source location 2019-0146-Response-by-Blackpool-Teaching-Hospitals-NHS-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 Existing admission medication reviews, clinical pharmacist assessments and in-Trust prescribing arrangements address essential medication availability.
Verbatim wording from the response “6) Approximate availability of essential medication – The practice in the Trust is that all patients on admission have their medication reviewed by the admitting doctor and are then seen by a clinical pharmacist and drugs are prescribed for use within the Trust.” Source location 2019-0146-Response-by-Blackpool-Teaching-Hospitals-NHS-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 Cost pressures have prevented implementation of the Electronic Document Management System, although a revised business case is being developed.
Verbatim wording from the response “2) Concern regarding record keeping – Whilst the Trust has made progress with electronic access to general practice records and partial provision of electronic records within the Emergency Department we have not as yet implemented an Electronic Document Management System (EDMS). A business case was approved by the Trust Board in January 2018 but because of more pressing cost pressures it has not been possible to progress this to date. A revised business case is in development and due for consideration by Executive Directors by the end of this month.” Source location 2019-0146-Response-by-Blackpool-Teaching-Hospitals-NHS-Trust
Open published response
8 Apr 2019 Tina Tait · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2 Failure to retain and make clinical records available View source Poor and illegible clinical record keeping 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
Tina Tait · 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
Tina Tait underwent elective ovarian cystectomy surgery on 8 May 2018 and subsequently experienced complications, including a colon perforation and later deterioration. She became unresponsive and died on 16 June 2018. The principal concern was the quality, legibility, accessibility and retention of clinical records, which delayed and compromised internal death reviews and could affect continuity of care and the learning of lessons.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain and make clinical records available
Wider context from the report “I bear in mind that the quality of record keeping is an issue I have raised with the hospital trust previously. In October 2017 I sent to the Trust a letter of concern written in accordance with paragraph 37 of the Chief Coroner’s Guidance No. 5 (Reports to prevent future deaths). That letter was in relation to investigations conducted at this court into the deaths of WB and NM. The letter was felt to be necessary after the inquest into WB’s death had to be conducted in the absence of documentation which the Trust was unable to locate . In May 2017 this court received from the Trust a Sudden Untoward Incident Review into the death of NM which had been completed in the absence of some of the hospital records which could not be located .
I was concerned that an improvement in relation to record keeping was essential because having access to quality documentation minimises the chance of, for example, an untoward clinical incident review being delayed or remaining incomplete; it avoids the risk that a coroner’s inquest is delayed. Also, and importantly in my view, it is obviously important that records are readily available to assist a coronial inquiry or indeed an internal hospital review not least in order to ensure any lessons which need to be learnt can be learnt and for this to be achieved as effectively as possible an accurate record of events should be available.
In addition to the quality of some of the records relating to Mrs Tait’s care in hospital, the Trust’s internal review was delayed because the clinical records could not be located for some time resulting in a delay before witness statements could be compiled and the Sudden Untoward Incident Review completed the impact of which was the inquest had to be vacated from the original court slot allocated to it and re-listed.
Other investigations have been affected by similar issues: a further investigation into the death of JS ultimately proceeded in the absence of hospital records which reportedly went missing after the death and could not be found .
In deciding to write this letter I take into account that in response to my letter in October 2017 [see above] I received a response from the Trust dated 4th December 2017 which explained that the point was made that “it is worth noting that the Trust has somewhere in excess of 500,000 sets of patient records and that non-availability is a rare event”. The letter went on to helpfully explain that the Executive Directors had approved a business case for the introduction of an electronic document management system which would mean paper records would be immediately accessible to attending clinicians.
Unfortunately, having monitored the situation since then I remain concerned that the Trust’s procedures in terms of accessibility but also to quality of clinical records pose a risk of future deaths if those procedures are jeopardising the likelihood of the correct lessons arising from a death investigation being learnt.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor and illegible clinical record keeping
Wider context from the report “The concern I have is that there is a risk of future deaths because the opportunity to learn valuable lessons following a death is being compromised by issues pertaining to the quality of record keeping.
Issues have arisen in relation to the quality of accessible clinical records [as in this inquest concerning Tina Tait] but also in relation to retention and storage of those records [other investigations – see below] to the extent that the effectiveness of sudden untoward incident reviews conducted by the Trust has been compromised perhaps due to the consequential delay [inevitably leading to lessons being learnt later than they may otherwise have been] or because the quality of the review has been affected [missing documentation leading to internal reviews having to be concluded in the absence of records].
Following Tina Tait’s death the hospital trust undertook a sudden untoward incident review. This led to a report being compiled and that document was included in the inquest evidence. One of the authors of that report, ████████
████████(Clinical Matron) gave extremely helpful evidence at the inquest and was an impressive witness.
However within the report a learning point was identified namely that the documentation in the case records had been found to be “at times poor and illegible” . [Other learning points included the need for improved handover / continuity of care, learning in relation to the recognition of a deteriorating patient and correct use of the Early Warning Score chart with appropriate escalation.] Professionals such as Amanda Langton tasked with investigating deaths clearly need to be provided with all of the necessary information to be able to produce an effective review which ensures the right lessons are learnt and the risk of future deaths minimised accordingly.
I am concerned that ████████ having found herself trying to review this matter in the face of poor and illegible records is a reminder that unless this type of issue is not addressed then risks will occur as a consequence. Medical professionals who take over the care of patients from other staff at handover need to be able to familiarise themselves with accessible and legible records. When this does not happen the quality of the care received by patients can be affected. It seems to me that issues persist as regards the quality of record keeping within the Trust and that it would be remiss of me not to raise that concern at this time.
” Open source report
28 Apr 2018 Catherine Burns · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2 Delays in doctor assessment after triage View source Insufficient staff capacity and time to assess and care for patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Catherine Burns · 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
Catherine Burns was admitted to hospital with abdominal pain, deteriorated during a prolonged wait for medical assessment, suffered respiratory arrest, and died on 5 December 2017. The principal concerns were emergency department workload, delayed medical assessment, insufficient monitoring, and failure to recognise deterioration promptly, creating a risk of future deaths.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in doctor assessment after triage
Wider context from the report “I am concerned that staff were unable to provide the level of care to Catherine Burns that they would have liked to provide or which they felt was appropriate and that that this was due to the number of patients they were expected to care for. Consequently deterioration in her condition was not appreciated as quickly as it may otherwise have been.
I am concerned that even during an extremely busy shift for a patient to be triaged as requiring assessment by a doctor and for that patient to then not be seen by a patient for over five hours risks future deaths and especially if the nursing staff are not able to monitor the patient as regularly as they may prefer.
When giving consideration to writing a report to prevent future deaths Coroners are not limited to deaths which are felt to have been contributed to by the issue causing the Coroner some concern. As stated above the care afforded to Mrs Burns did not in my view alter the outcome for her but this should not prevent this report being written if I believe the duty upon me is met.
I received impressive evidence from a Sister whose role was to co-ordinate the assessment area. She explained that during the entirety of the shift the staff had been dealing with approximately one third more patients than when they are performing at what is usually regarded as full capacity. However this was not an isolated incident and this had been the position throughout December, January, and February and that it has remained an issue which is persisting and cannot be solely attributed to what is sometimes described as “winter pressures”.
It may well come as no surprise that the Emergency Department staff is facing these pressures and it may be that you feel that as a Trust you are doing all that you feel that you can to minimise the impact caused by the increased workload. Indeed I received helpful evidence during the inquest from the co-ordinator of the Emergency Department who explained that efforts have been made to review practices in order to make the system more efficient and hopefully be able to cope with over-capacity.
Nevertheless, I believe that I have a duty to write this letter because I feel that there is a risk of future deaths caused or contributed to by staff not having the time to assess and care for patients due to their workload meaning any potentially significant deterioration in a patient’s condition may go unrecognised or is under-appreciated and with serious consequences.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff capacity and time to assess and care for patients
Wider context from the report “I am concerned that staff were unable to provide the level of care to Catherine Burns that they would have liked to provide or which they felt was appropriate and that that this was due to the number of patients they were expected to care for . Consequently deterioration in her condition was not appreciated as quickly as it may otherwise have been.
I am concerned that even during an extremely busy shift for a patient to be triaged as requiring assessment by a doctor and for that patient to then not be seen by a patient for over five hours risks future deaths and especially if the nursing staff are not able to monitor the patient as regularly as they may prefer.
When giving consideration to writing a report to prevent future deaths Coroners are not limited to deaths which are felt to have been contributed to by the issue causing the Coroner some concern. As stated above the care afforded to Mrs Burns did not in my view alter the outcome for her but this should not prevent this report being written if I believe the duty upon me is met.
I received impressive evidence from a Sister whose role was to co-ordinate the assessment area. She explained that during the entirety of the shift the staff had been dealing with approximately one third more patients than when they are performing at what is usually regarded as full capacity . However this was not an isolated incident and this had been the position throughout December, January, and February and that it has remained an issue which is persisting and cannot be solely attributed to what is sometimes described as “winter pressures”.
It may well come as no surprise that the Emergency Department staff is facing these pressures and it may be that you feel that as a Trust you are doing all that you feel that you can to minimise the impact caused by the increased workload. Indeed I received helpful evidence during the inquest from the co-ordinator of the Emergency Department who explained that efforts have been made to review practices in order to make the system more efficient and hopefully be able to cope with over-capacity.
Nevertheless, I believe that I have a duty to write this letter because I feel that there is a risk of future deaths caused or contributed to by staff not having the time to assess and care for patients due to their workload meaning any potentially significant deterioration in a patient’s condition may go unrecognised or is under-appreciated and with serious consequences.
At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Better Care Now programme to improve patient flow across the health system.
Verbatim wording from the response “The Better Care Now programme led by myself as Medical Director is in place to improve patient flow through the whole health system. As this programme begins to deliver, the pressure of overcrowding in the Emergency Department will begin to ease.” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide triage nurses at reception to improve streaming and fast initial assessment.
Verbatim wording from the response “Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement an Escalation and Surge Protocol with agreed escalation criteria and assigned actions.
Verbatim wording from the response “As part of that programme of work, the Department is developing an Escalation and Surge Protocol to help coordinate a consistent and effective response to an increase in demand. The criteria for escalation has been agreed and includes an escalation in the wait to be seen. Actions are being assigned to support the nurse and doctor in charge of the Emergency Department to manage the pressure effectively and gain the support required to de-escalate. Escalation is being assessed through two hourly Safety Huddles and six times daily at bed meetings.” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Introduce a centralised control room to improve operational management of patient flow.
Verbatim wording from the response “Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the SAFER care bundle to improve ward patient management and discharge planning.
Verbatim wording from the response “Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Identify, escalate and safely manage medical and nursing staffing gaps through governance arrangements.
Verbatim wording from the response “Until such time as an increase in establishment has been agreed, the Department continues to recruit substantively to vacancies and cover staffing safely on a day to day, shift by shift basis. There are robust governance structures in place to ensure that both medical and nursing staffing gaps are identified early, escalated and managed safely.” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 substantive recruitment to staffing vacancies and provide safe day-to-day shift cover.
Verbatim wording from the response “Until such time as an increase in establishment has been agreed, the Department continues to recruit substantively to vacancies and cover staffing safely on a day to day, shift by shift basis. There are robust governance structures in place to ensure that both medical and nursing staffing gaps are identified early, escalated and managed safely.” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Prepare and submit a paper seeking approval for increased Emergency Department staffing establishment.
Verbatim wording from the response “In response to the increase in demand on ED, the Emergency Department has undertaken a capacity and demand review of nursing and medical staffing and found that an increase in establishment is required. Accordingly, a paper has been prepared and submitted to the Executive Team for consideration.” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Complete a capacity and demand review of Emergency Department nursing and medical staffing.
Verbatim wording from the response “In response to the increase in demand on ED, the Emergency Department has undertaken a capacity and demand review of nursing and medical staffing and found that an increase in establishment is required. Accordingly, a paper has been prepared and submitted to the Executive Team for consideration.” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce therapies in the Emergency Department to accelerate admission or discharge decisions.
Verbatim wording from the response “Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-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 Maximise Ambulatory Emergency Care pathways so suitable patients are managed outside the Emergency Department.
Verbatim wording from the response “Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing recruitment, shift-by-shift staffing and governance arrangements are considered sufficient to identify, escalate and safely manage staffing gaps pending establishment approval.
Verbatim wording from the response “Until such time as an increase in establishment has been agreed, the Department continues to recruit substantively to vacancies and cover staffing safely on a day to day, shift by shift basis. There are robust governance structures in place to ensure that both medical and nursing staffing gaps are identified early, escalated and managed safely.” Source location 2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Open published response
16 Jan 2018 Mr Keith James Harwood · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2 Failure to ensure medical staff have the requisite knowledge of condition implications without relying on families View source Failure to obtain requisite specialist advice for unfamiliar conditions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Keith James Harwood · 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
Mr Keith James Harwood underwent elective cardiac surgery in July 2014 and subsequently suffered a cardiac arrest and hypoxic brain injury, leaving him in a persistent vegetative state. He later died on 29 December 2016 from the combined effects of bronchopneumonia and a sub-phrenic abscess. Concerns included inadequate recognition of the complexity of his Parkinson’s disease and uncertainty about how hospital staff could obtain timely specialist neurological advice for patients with complex conditions.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medical staff have the requisite knowledge of condition implications without relying on families
Wider context from the report “However, I have concerns that despite the introduction of a Trust policy, the evidence heard at this inquest suggests that medical professionals may find themselves in a position whereby, as with events surrounding Mr Harwood’s care, they are faced with an unfamiliar condition and without being able to source the requisite (possibly urgent) specialist advice.
The co-author of the SUI review was unsure about what assistance would be available particularly in relation to neurology input.
I remain therefore concerned that a family such as Mr Harwood’s may find themselves in being asked to educate medical staff about the potential implications of a certain condition. .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain requisite specialist advice for unfamiliar conditions
Wider context from the report “However, I have concerns that despite the introduction of a Trust policy, the evidence heard at this inquest suggests that medical professionals may find themselves in a position whereby, as with events surrounding Mr Harwood’s care, they are faced with an unfamiliar condition and without being able to source the requisite (possibly urgent) specialist advice .
The co-author of the SUI review was unsure about what assistance would be available particularly in relation to neurology input.
I remain therefore concerned that a family such as Mr Harwood’s may find themselves in being asked to educate medical staff about the potential implications of a certain condition..
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint a consultant physician with specific expertise in managing Parkinson’s disease.
Verbatim wording from the response “I write in response to your Regulation 28 report to prevent future deaths in respect of Mr Keith Harwood. The events surrounding Mr Harwood’s care date from July 2014 and relate to the management of his Parkinson’s disease. At that time Neurological advice for patients in the Trust suffering from Parkinson’s disease was provided by a visiting Consultant Neurologist from Lancashire Teaching Hospitals NHS Foundation Trust. In August 2016 the Trust appointed a Consultant Physician in Care of the Elderly who has specific expertise and interest in the management of Parkinson’s disease. In December 2016 he co-authored a procedure for the acute management of in-patients with Parkinson’s disease and you have had sight of this.” Source location 2018-0017-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Co-author a procedure for the acute management of inpatients with Parkinson’s disease.
Verbatim wording from the response “I write in response to your Regulation 28 report to prevent future deaths in respect of Mr Keith Harwood. The events surrounding Mr Harwood’s care date from July 2014 and relate to the management of his Parkinson’s disease. At that time Neurological advice for patients in the Trust suffering from Parkinson’s disease was provided by a visiting Consultant Neurologist from Lancashire Teaching Hospitals NHS Foundation Trust. In August 2016 the Trust appointed a Consultant Physician in Care of the Elderly who has specific expertise and interest in the management of Parkinson’s disease. In December 2016 he co-authored a procedure for the acute management of in-patients with Parkinson’s disease and you have had sight of this.” Source location 2018-0017-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue an internal alert reminding staff about timely Parkinson’s disease management, specialist referral and access to the procedure on the Trust intranet.
Verbatim wording from the response “I shall as a consequence of your communication be issuing an internal alert within the Trust reminding all staff of the importance of timely management of patients with Parkinson’s disease, timely referral to the Parkinson’s Specialist Team and the availability of the procedure document on the Trust intranet.” Source location 2018-0017-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing Parkinson’s disease procedure and specialist contact arrangements provide sufficient access to timely advice and assistance when required.
Verbatim wording from the response “Notwithstanding the uncertainty expressed to you by the co-author of the SUI review about what assistance would be available to patients, section 2 on page 3 of the procedure explicitly states the importance of early involvement of the Parkinson’s Specialist Team and contact details are provided in section 3.8 on page 14. These details include contact numbers for the Parkinson’s Disease Nurse Specialist, the Consultant Physician and helplines, one of which is specific to the management of patients with Apomorphine infusion. That advice and training from the pharmaceutical company is readily available at immediate notice if required.” Source location 2018-0017-Response
Open published response
10 Oct 2017 Bernard Cosgrove · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Failure to effectively monitor patients for developing clinical problems View source Failure to consider relevant previous medical record entries in subsequent patient care View source Failure to incorporate identified clinical findings into subsequent nursing care plans View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bernard Cosgrove · 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
Bernard Cosgrove was admitted to hospital on 28 February 2017 after being observed unresponsive and was discharged to his nursing home on 10 March 2017 with a dislocated right hip joint that had started to become infected. He died at the nursing home on 21 March 2017 from bronchopneumonia, with significant heart disease and hip joint infection contributing to his death. The principal concerns were that the dislocation was not recognised for seven days, that relevant medical-record information was not incorporated into his care, and that patient monitoring and consideration of medical records were insufficient.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively monitor patients for developing clinical problems
Wider context from the report “The concerns are:
• Despite an entry in the clinical records made by a doctor on 3rd March 2017 which refers to a rotating right leg, neither the issue he identifies nor his entry in the notes appear to have been appreciated by nursing staff who cared for Mr Cosgrove thereafter. A Sister who was a clear and helpful witness acknowledged in court that the issue identified by the doctor on 3rd March 2017 was not considered as part of his plan of care subsequently. This is despite the fact that between 3rd March 2017 and discharge from hospital he was seen regularly by staff with responsibility for physically rolling him with a view to providing pressure relief.
• Although from the evidence it is not known how the dislocation occurred the fact it does not appear to have been recognised over a period of 7 days is concerning and strongly suggests that staff paid insufficient regard to the patient's previous medical record entries. Patients such as Mr Cosgrove should not find themselves being discharged from hospital in such circumstances and at a time when the medical professionals looking after his welfare are unaware of such an issue.
• But for the fact he was discharged from hospital on 10th March 2017 and that this resulted in the dislocation problem being identified, had he spent a lengthier period in hospital the dislocation and developing infection may well have continued to go unrecognised which raises a concern about how effectively patients are being monitored and their medical records are being considered by staff who are subsequently involved in that patient's care. On this occasion once the dislocation issue was identified this did not substantially alter his care and he was treated conservatively, but in other circumstances not recognising the problem may have directly caused a death.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider relevant previous medical record entries in subsequent patient care
Wider context from the report “The concerns are:
• Despite an entry in the clinical records made by a doctor on 3rd March 2017 which refers to a rotating right leg, neither the issue he identifies nor his entry in the notes appear to have been appreciated by nursing staff who cared for Mr Cosgrove thereafter. A Sister who was a clear and helpful witness acknowledged in court that the issue identified by the doctor on 3rd March 2017 was not considered as part of his plan of care subsequently. This is despite the fact that between 3rd March 2017 and discharge from hospital he was seen regularly by staff with responsibility for physically rolling him with a view to providing pressure relief.
• Although from the evidence it is not known how the dislocation occurred the fact it does not appear to have been recognised over a period of 7 days is concerning and strongly suggests that staff paid insufficient regard to the patient's previous medical record entries . Patients such as Mr Cosgrove should not find themselves being discharged from hospital in such circumstances and at a time when the medical professionals looking after his welfare are unaware of such an issue.
• But for the fact he was discharged from hospital on 10th March 2017 and that this resulted in the dislocation problem being identified, had he spent a lengthier period in hospital the dislocation and developing infection may well have continued to go unrecognised which raises a concern about how effectively patients are being monitored and their medical records are being considered by staff who are subsequently involved in that patient's care. On this occasion once the dislocation issue was identified this did not substantially alter his care and he was treated conservatively, but in other circumstances not recognising the problem may have directly caused a death.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate identified clinical findings into subsequent nursing care plans
Wider context from the report “The concerns are:
• Despite an entry in the clinical records made by a doctor on 3rd March 2017 which refers to a rotating right leg, neither the issue he identifies nor his entry in the notes appear to have been appreciated by nursing staff who cared for Mr Cosgrove thereafter . A Sister who was a clear and helpful witness acknowledged in court that the issue identified by the doctor on 3rd March 2017 was not considered as part of his plan of care subsequently . This is despite the fact that between 3rd March 2017 and discharge from hospital he was seen regularly by staff with responsibility for physically rolling him with a view to providing pressure relief.
• Although from the evidence it is not known how the dislocation occurred the fact it does not appear to have been recognised over a period of 7 days is concerning and strongly suggests that staff paid insufficient regard to the patient's previous medical record entries. Patients such as Mr Cosgrove should not find themselves being discharged from hospital in such circumstances and at a time when the medical professionals looking after his welfare are unaware of such an issue.
• But for the fact he was discharged from hospital on 10th March 2017 and that this resulted in the dislocation problem being identified, had he spent a lengthier period in hospital the dislocation and developing infection may well have continued to go unrecognised which raises a concern about how effectively patients are being monitored and their medical records are being considered by staff who are subsequently involved in that patient's care. On this occasion once the dislocation issue was identified this did not substantially alter his care and he was treated conservatively, but in other circumstances not recognising the problem may have directly caused a death.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use an electronic ward-level tracking system to flag critical activities until they are actioned.
Verbatim wording from the response “A problem with his hip was suspected by the attending Physician who ordered an x-ray on 3 March 2017. Unfortunately this Physician was a locum who left on that date and the outstanding request for an x-ray investigation was not pursued by his successor who was also a locum. Since that time the Trust has introduced an electronic tracking system on every ward” Source location 2017-0285-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide ward-based education, updates and reminders supporting professional responsibility for patient care and contemporaneous recordkeeping.
Verbatim wording from the response “The Trust notes your concern in terms of other potential circumstances where not recognising issues or recording specific history within patient notes could lead to future problems and we are working hard to eradicate such problems. We work closely with our staff in terms of practice development and continued professional development through Ward based education, updates and reminders of their professional responsibility in terms of patient care and contemporaneous recording of observations and notes.” Source location 2017-0285-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement lessons learned from the internal review of patient care.
Verbatim wording from the response “It is acknowledged that, sadly, the necessity to x-ray Mr Cosgrove’s hip was not acted upon post the recommendation on the 3rd March 2017. The nursing staff continued with Mr Cosgrove’s plan of care until his discharge on the 10th March 2017, this included a strict turning regime given his susceptibility to developing pressure damage, which for a patient like Mr Cosgrove could have been fatal. The Trust cannot, identify why, in Mr Cosgrove’s case, there was no further record or action taken in terms of investigation into the potential findings from the 3rd March 2017 and for this we apologise. However, having undertaken an internal review of Mr Cosgrove’s care, lessons have been learnt and are being implemented.” Source location 2017-0285-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Open published response
11 Oct 2016 Barry THOMPSON · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 10 Lack of clear instructions and staff knowledge for monitoring diabetic patients with sepsis View source Failure of intravenous infusion delivery to provide the intended fluid dose View source Delays in timely medical review and antibiotic treatment for high-priority patients View source Failure of the three-tier system to transfer key patient information quickly View source Inaccurate, infrequent, disjointed and incomplete clinical record keeping View source Failure to administer and prescribe required repeat antibiotics and insulin View source Failure to assess the significance of patients’ existing comorbidity medication View source Failure to act on elevated National Early Warning Scores View source Failure to provide food and maintain adequate fluid-balance records View source Failure to provide medical review on the acute medical unit View source See 7 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
Barry THOMPSON · 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
Barry Thompson, an insulin-dependent diabetic, died on 27 February 2016 while a patient on the Acute Medical Unit, after being admitted with sepsis from diabetic foot ulcers and hyperglycaemia. The report identified concerns about failure to provide insulin, fluids, adequate monitoring, antibiotics and medical review, as well as inaccurate and incomplete records and ineffective information sharing during transfer between departments.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear instructions and staff knowledge for monitoring diabetic patients with sepsis
Wider context from the report “(2) Managing a diabetic patient.
Instructions were not given as to how frequently Mr Thompson’s blood sugar and ketones should be monitored. The evidence was that this should be every hour. After 16.15 hours there was one measurement of blood sugar and a later recording on the acute medical unit (untimed) and no measurement of ketones. It is of concern that staff were not clear how frequently to monitor a diabetic patient, nor are with a concomitant condition i.e. sepsis, or where to locate a Ketone box for testing .Diabetes is a very common medical problem which hospital staff encounter frequently. Another inquest approximately 18 months ago was heard at Blackpool concerning the management of a diabetic patient where, although the facts and personnel differed the same conclusion was recorded. In that case the author of the Serious Incident Review concluded there was a lack of “joined up thinking”.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of intravenous infusion delivery to provide the intended fluid dose
Wider context from the report “(3) Monitoring patients’ basic needs.
There was difficulty encountered giving Mr Thompson saline by way of a drip. He was given an infusion of 1 litre over 4 hours at 17.30. At 23.00 it was found that the original cannula had become detached but the remaining fluid in the sac was 700mls. Mr Thompson’s bed was wet with saline fluid. He did not therefore receive the intended dose. He was not given a further injection of antibiotics 6 hours after the first nor was he written up for it. He was not given insulin. He does not appear to have been given any food whilst a patient or adequate fluid balance charts maintained. He was not seen by a doctor on the AMU. He was on a range of medication on admission to hospital for co-morbidities. The importance of this or otherwise was not assessed by staff.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in timely medical review and antibiotic treatment for high-priority patients
Wider context from the report “(1) Non-compliance with National and Local protocols:
Mr Thompson was triaged as a high priority on admission to the Emergency department at 12.37 am on 26th February 2016. It is recorded that he not had his morning insulin. He was not seen by a doctor nor given antibiotics within an hour according to the National Standard and the (Hospital’s) Sepsis Pathway. He was seen by a doctor at 16.52 (although his case was drawn to the attention of a doctor earlier by a nurse and instructions given for care). Further a NEWS score of 7 (National Early Warning Score) was not actioned according to policy which would have resulted in Mr Thompson being reviewed by at least middle grade doctor immediately.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the three-tier system to transfer key patient information quickly
Wider context from the report “(4) Record keeping. /Information sharing.
I found on hearing the evidence that records from both departments from 16.52 onwards are inaccurate, infrequently made, disjointed and are incomplete causing them to be unreliable and affected continuity of care. Also this caused staff at the inquest not to be able to fully recall their actions.
There was a 3 stage system in place to ensure transfer of important information about Mr Thompson when he moved from the ED to the AMU.
a) A SBAR document is completed by the transferring nurse who accompanies the patient. In this case the document does not state (despite there being provision on the form) who that person was or who the receiving nurse was. It does not identify Mr Thompson as a diabetic nor state he has not had his insulin. It erroneously states he is not on a sepsis pathway.
b) There is a computerised tracking system providing for doctors in the ED to transfer key information about a patient to the doctors on the AMU. This then serves as a live reference point for staff on the ward. In this case the information refers to Mr Thompson having cellulitis only and makes no reference to his diabetes. This affected the prioritisation of Mr Thompson on the AMU particularly when it came to observations and testing needed and review by a doctor.
c) The evidence from the ED matron was that either the named nurse or department co-ordinator should share key information by telephone with the ward prior to transfer. I concluded this did not occur as neither said they could remember doing so nor was there a record.
The remainder of case notes which had come into existence whilst Mr Thompson was in the ED did go to the ward with him and referred to his diabetes and earlier assessments but
I am concerned that the 3 tier system put in place to share key information quickly is not working.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate, infrequent, disjointed and incomplete clinical record keeping
Wider context from the report “(4) Record keeping. /Information sharing.
I found on hearing the evidence that records from both departments from 16.52 onwards are inaccurate, infrequently made, disjointed and are incomplete causing them to be unreliable and affected continuity of care . Also this caused staff at the inquest not to be able to fully recall their actions.
There was a 3 stage system in place to ensure transfer of important information about Mr Thompson when he moved from the ED to the AMU.
a) A SBAR document is completed by the transferring nurse who accompanies the patient. In this case the document does not state (despite there being provision on the form) who that person was or who the receiving nurse was. It does not identify Mr Thompson as a diabetic nor state he has not had his insulin. It erroneously states he is not on a sepsis pathway.
b) There is a computerised tracking system providing for doctors in the ED to transfer key information about a patient to the doctors on the AMU. This then serves as a live reference point for staff on the ward. In this case the information refers to Mr Thompson having cellulitis only and makes no reference to his diabetes. This affected the prioritisation of Mr Thompson on the AMU particularly when it came to observations and testing needed and review by a doctor.
c) The evidence from the ED matron was that either the named nurse or department co-ordinator should share key information by telephone with the ward prior to transfer. I concluded this did not occur as neither said they could remember doing so nor was there a record.
The remainder of case notes which had come into existence whilst Mr Thompson was in the ED did go to the ward with him and referred to his diabetes and earlier assessments but
I am concerned that the 3 tier system put in place to share key information quickly is not working.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer and prescribe required repeat antibiotics and insulin
Wider context from the report “(3) Monitoring patients’ basic needs.
There was difficulty encountered giving Mr Thompson saline by way of a drip. He was given an infusion of 1 litre over 4 hours at 17.30. At 23.00 it was found that the original cannula had become detached but the remaining fluid in the sac was 700mls. Mr Thompson’s bed was wet with saline fluid. He did not therefore receive the intended dose. He was not given a further injection of antibiotics 6 hours after the first nor was he written up for it. He was not given insulin. He does not appear to have been given any food whilst a patient or adequate fluid balance charts maintained. He was not seen by a doctor on the AMU. He was on a range of medication on admission to hospital for co-morbidities. The importance of this or otherwise was not assessed by staff.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess the significance of patients’ existing comorbidity medication
Wider context from the report “(3) Monitoring patients’ basic needs.
There was difficulty encountered giving Mr Thompson saline by way of a drip. He was given an infusion of 1 litre over 4 hours at 17.30. At 23.00 it was found that the original cannula had become detached but the remaining fluid in the sac was 700mls. Mr Thompson’s bed was wet with saline fluid. He did not therefore receive the intended dose. He was not given a further injection of antibiotics 6 hours after the first nor was he written up for it. He was not given insulin. He does not appear to have been given any food whilst a patient or adequate fluid balance charts maintained. He was not seen by a doctor on the AMU. He was on a range of medication on admission to hospital for co-morbidities. The importance of this or otherwise was not assessed by staff.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on elevated National Early Warning Scores
Wider context from the report “(1) Non-compliance with National and Local protocols:
Mr Thompson was triaged as a high priority on admission to the Emergency department at 12.37 am on 26th February 2016. It is recorded that he not had his morning insulin. He was not seen by a doctor nor given antibiotics within an hour according to the National Standard and the (Hospital’s) Sepsis Pathway. He was seen by a doctor at 16.52 (although his case was drawn to the attention of a doctor earlier by a nurse and instructions given for care). Further a NEWS score of 7 (National Early Warning Score) was not actioned according to policy which would have resulted in Mr Thompson being reviewed by at least middle grade doctor immediately .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide food and maintain adequate fluid-balance records
Wider context from the report “(3) Monitoring patients’ basic needs.
There was difficulty encountered giving Mr Thompson saline by way of a drip. He was given an infusion of 1 litre over 4 hours at 17.30. At 23.00 it was found that the original cannula had become detached but the remaining fluid in the sac was 700mls. Mr Thompson’s bed was wet with saline fluid. He did not therefore receive the intended dose. He was not given a further injection of antibiotics 6 hours after the first nor was he written up for it. He was not given insulin. He does not appear to have been given any food whilst a patient or adequate fluid balance charts maintained. He was not seen by a doctor on the AMU. He was on a range of medication on admission to hospital for co-morbidities. The importance of this or otherwise was not assessed by staff.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide medical review on the acute medical unit
Wider context from the report “(3) Monitoring patients’ basic needs.
There was difficulty encountered giving Mr Thompson saline by way of a drip. He was given an infusion of 1 litre over 4 hours at 17.30. At 23.00 it was found that the original cannula had become detached but the remaining fluid in the sac was 700mls. Mr Thompson’s bed was wet with saline fluid. He did not therefore receive the intended dose. He was not given a further injection of antibiotics 6 hours after the first nor was he written up for it. He was not given insulin. He does not appear to have been given any food whilst a patient or adequate fluid balance charts maintained. He was not seen by a doctor on the AMU. He was on a range of medication on admission to hospital for co-morbidities. The importance of this or otherwise was not assessed by staff.
” Open source report
Concerns raised 4 Failure to follow NICE guidelines View source Failure to maintain appropriate records View source Failure to follow NMC guidance View source Failure to develop appropriate care plans View source See 1 more concern
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
Dorothy Imsson · 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
Dorothy Imsson died at Cleveleys Nursing Home on 9 August 2014 from a naturally occurring stroke caused by atrial fibrillation. Her death was contributed to by the absence of pressure care planning by qualified staff, resulting in severe skin ulceration, a shortening of life, and increased pain and suffering. Concerns also included the District Nursing Service's failure to develop an appropriate care plan and alleged failures to follow NMC guidance, record-keeping requirements, and NICE guidelines.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow NICE guidelines
Wider context from the report “(1) No appropriate care plan was developed by the District Nursing Service.
(2) The District Nursing Service are compromising patient care by not following NMC guidance or record keeping
(3) The District Nursing Services are compromising patient care by not following NICE guidelines .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain appropriate records
Wider context from the report “(1) No appropriate care plan was developed by the District Nursing Service.
(2) The District Nursing Service are compromising patient care by not following NMC guidance or record keeping
(3) The District Nursing Services are compromising patient care by not following NICE guidelines.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow NMC guidance
Wider context from the report “(1) No appropriate care plan was developed by the District Nursing Service.
(2) The District Nursing Service are compromising patient care by not following NMC guidance or record keeping
(3) The District Nursing Services are compromising patient care by not following NICE guidelines.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to develop appropriate care plans
Wider context from the report “(1) No appropriate care plan was developed by the District Nursing Service.
(2) The District Nursing Service are compromising patient care by not following NMC guidance or record keeping
(3) The District Nursing Services are compromising patient care by not following NICE guidelines.
” Open source report
22 May 2015 Olive Darbyshire · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 4 Failure to complete urgent CTPA requests promptly View source Failure of the clinical team to follow up missing CTPA procedures View source Incorrect categorisation of urgent CTPA requests as outpatient requests View source Failure to process urgent CTPA requests during holiday periods 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
Olive Darbyshire · 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
Olive Darbyshire fell while trying to get from her bed to the toilet, suffered a hip fracture, and was admitted to hospital. An urgent CT pulmonary angiogram requested after suspected pulmonary embolism was not carried out after she was incorrectly categorised as an outpatient, and she later developed a major intestinal bleed and died on 28 December 2014. Concerns included the failure to complete or follow up the urgent scan and the effects of incorrect categorisation and reduced Christmas-period staffing.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete urgent CTPA requests promptly
Wider context from the report “1. Although it is not possible to say whether a CTPA procedure would have had an impact upon when Mrs Darbyshire died, I am concerned that two senior Doctors gave evidence that they were expecting an urgent CTPA to have taken place and that this had not happened some three days after the request was made .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the clinical team to follow up missing CTPA procedures
Wider context from the report “2. I am concerned that according to the Radiology department there is no record of the clinical team responsible for Mrs Darbyshire's care making efforts to “chase up” the missing CTPA procedure .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incorrect categorisation of urgent CTPA requests as outpatient requests
Wider context from the report “3. I am concerned that the radiology department staff have incorrectly categorised Mrs Darbyshire in a way that meant that she spent a number of days in hospital awaiting an urgent CTPA procedure that in reality was not going to happen because once categorised as an outpatient she realistically would only expect to receive a CTPA in 2015 by way of a written notification .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to process urgent CTPA requests during holiday periods
Wider context from the report “4. I am concerned that given this request was made on 23rd December 2014, subsequent events have been influenced by the fact that the request was made shortly before the Christmas period and that a lack of action taken by the clinical team to “chase up” the CTPA and the actions of the radiology department administration staff have been influenced by reduced staffing levels over the Christmas holiday period when the department would deal with inpatient requests only, and emergency requests pertaining to Accident & Emergency patients .
” 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 Ratify the procedure within the directorate, submit it to the electronic Trust document library, and provide paper copies in key radiology areas.
Verbatim wording from the response “This will be ratified within the directorate and submitted to the Trust document library, where it can be accessed electronically by all staff, at any time.” Source location Olive-Darbyshire-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 Create a standard operating procedure for recording and tracing diagnostic-request status changes, messages, requested actions and authorisation.
Verbatim wording from the response “There have been several meetings of key team leaders and staff to look at how the Trust can put in place measures to reduce the weaknesses regarding the status of diagnostic requests, identification of the individual making the request, messaging and follow up.” Source location Olive-Darbyshire-Response
Open published response
27 Nov 2014 Freda Virginia Owens · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 5 Unrecognised incorrect assumptions about the cause of a patient’s injury View source Failure to examine a high-risk patient area View source Delays in involving the tissue viability specialist View source Failure to provide relevant patient information to involved medical professionals View source Failure to communicate clinical assessment information between relevant specialist teams 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
Freda Virginia Owens · 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
Freda Virginia Owens, aged 93, died after developing bronchopneumonia associated with an infected necrotic pressure ulcer of the left hip, alongside burns and scalds sustained on 2 November 2012. The report identified concerns about the gathering and exchange of information between care and medical professionals, delays in recognising the pressure ulcer, and the resulting delay in treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unrecognised incorrect assumptions about the cause of a patient’s injury
Wider context from the report “I now write to the two Hospital Trusts and to the Croft House Rest Home to confirm that in my view action should be taken because there is a concern about the quality of the gathering and exchange of information between the various medical professionals involved in Mrs. Owens’s care for the following reasons:
1. A District Nurse was unaware of potentially important information as regards the Patient including how restricted her movement was.
2. Having considered all of the oral evidence in court and the clinical records, the amount and quality of the information provided to the hospital is limited and this had an impact upon later decisions taken and not least by the Tissue Viability Nurse once she was involved.
3. Although the District Nurse explained why she did not examine the Deceased’s left hip area on 21st November 2012, the Nurse in my view ought to have examined that area given the Patient was viewed as being at high risk of developing pressure areas. Such examination may have prompted her, given her professional experience, to recognise a pressure area as distinct from a burn / scald and that information may then have been communicated on to hospital staff who would have then most likely involved the Tissue Viability Nurse more quickly reducing the chances of an incorrect assumption being made that the hip area was problematic as a result of a pressure area and not due to burns inflicted on 2nd November 2012. However, having chosen not to do so this was not then communicated to other medical professionals involved in her care for them to assess.
4. That following arrival and assessment at the Royal Preston Hospital, that there was a lack of communication between the clinical team and the plastic surgery team, which appears to have contributed to the fact that it was not until 3rd December 2012 when the Tissue Viability Nurse became involved.
These issues as regards the gathering and exchange of information as regards this Patient raise concerns that an incorrect assumption – such as the one made that Mrs Owens hip area was damaged due to the incident involving the commode on 2nd November 2012 - may arise in a future case and with fatal consequences if such an incorrect assumption were not to be recognised early enough to positively affect a Patient’s outcome .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to examine a high-risk patient area
Wider context from the report “I now write to the two Hospital Trusts and to the Croft House Rest Home to confirm that in my view action should be taken because there is a concern about the quality of the gathering and exchange of information between the various medical professionals involved in Mrs. Owens’s care for the following reasons:
1. A District Nurse was unaware of potentially important information as regards the Patient including how restricted her movement was.
2. Having considered all of the oral evidence in court and the clinical records, the amount and quality of the information provided to the hospital is limited and this had an impact upon later decisions taken and not least by the Tissue Viability Nurse once she was involved.
3. Although the District Nurse explained why she did not examine the Deceased’s left hip area on 21st November 2012, the Nurse in my view ought to have examined that area given the Patient was viewed as being at high risk of developing pressure areas . Such examination may have prompted her, given her professional experience, to recognise a pressure area as distinct from a burn / scald and that information may then have been communicated on to hospital staff who would have then most likely involved the Tissue Viability Nurse more quickly reducing the chances of an incorrect assumption being made that the hip area was problematic as a result of a pressure area and not due to burns inflicted on 2nd November 2012. However, having chosen not to do so this was not then communicated to other medical professionals involved in her care for them to assess.
4. That following arrival and assessment at the Royal Preston Hospital, that there was a lack of communication between the clinical team and the plastic surgery team, which appears to have contributed to the fact that it was not until 3rd December 2012 when the Tissue Viability Nurse became involved.
These issues as regards the gathering and exchange of information as regards this Patient raise concerns that an incorrect assumption – such as the one made that Mrs Owens hip area was damaged due to the incident involving the commode on 2nd November 2012 - may arise in a future case and with fatal consequences if such an incorrect assumption were not to be recognised early enough to positively affect a Patient’s outcome.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in involving the tissue viability specialist
Wider context from the report “I now write to the two Hospital Trusts and to the Croft House Rest Home to confirm that in my view action should be taken because there is a concern about the quality of the gathering and exchange of information between the various medical professionals involved in Mrs. Owens’s care for the following reasons:
1. A District Nurse was unaware of potentially important information as regards the Patient including how restricted her movement was.
2. Having considered all of the oral evidence in court and the clinical records, the amount and quality of the information provided to the hospital is limited and this had an impact upon later decisions taken and not least by the Tissue Viability Nurse once she was involved.
3. Although the District Nurse explained why she did not examine the Deceased’s left hip area on 21st November 2012, the Nurse in my view ought to have examined that area given the Patient was viewed as being at high risk of developing pressure areas. Such examination may have prompted her, given her professional experience, to recognise a pressure area as distinct from a burn / scald and that information may then have been communicated on to hospital staff who would have then most likely involved the Tissue Viability Nurse more quickly reducing the chances of an incorrect assumption being made that the hip area was problematic as a result of a pressure area and not due to burns inflicted on 2nd November 2012. However, having chosen not to do so this was not then communicated to other medical professionals involved in her care for them to assess.
4. That following arrival and assessment at the Royal Preston Hospital, that there was a lack of communication between the clinical team and the plastic surgery team, which appears to have contributed to the fact that it was not until 3rd December 2012 when the Tissue Viability Nurse became involved .
These issues as regards the gathering and exchange of information as regards this Patient raise concerns that an incorrect assumption – such as the one made that Mrs Owens hip area was damaged due to the incident involving the commode on 2nd November 2012 - may arise in a future case and with fatal consequences if such an incorrect assumption were not to be recognised early enough to positively affect a Patient’s outcome.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide relevant patient information to involved medical professionals
Wider context from the report “I now write to the two Hospital Trusts and to the Croft House Rest Home to confirm that in my view action should be taken because there is a concern about the quality of the gathering and exchange of information between the various medical professionals involved in Mrs. Owens’s care for the following reasons:
1. A District Nurse was unaware of potentially important information as regards the Patient including how restricted her movement was.
2. Having considered all of the oral evidence in court and the clinical records, the amount and quality of the information provided to the hospital is limited and this had an impact upon later decisions taken and not least by the Tissue Viability Nurse once she was involved.
3. Although the District Nurse explained why she did not examine the Deceased’s left hip area on 21st November 2012, the Nurse in my view ought to have examined that area given the Patient was viewed as being at high risk of developing pressure areas. Such examination may have prompted her, given her professional experience, to recognise a pressure area as distinct from a burn / scald and that information may then have been communicated on to hospital staff who would have then most likely involved the Tissue Viability Nurse more quickly reducing the chances of an incorrect assumption being made that the hip area was problematic as a result of a pressure area and not due to burns inflicted on 2nd November 2012. However, having chosen not to do so this was not then communicated to other medical professionals involved in her care for them to assess.
4. That following arrival and assessment at the Royal Preston Hospital, that there was a lack of communication between the clinical team and the plastic surgery team, which appears to have contributed to the fact that it was not until 3rd December 2012 when the Tissue Viability Nurse became involved.
These issues as regards the gathering and exchange of information as regards this Patient raise concerns that an incorrect assumption – such as the one made that Mrs Owens hip area was damaged due to the incident involving the commode on 2nd November 2012 - may arise in a future case and with fatal consequences if such an incorrect assumption were not to be recognised early enough to positively affect a Patient’s outcome.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate clinical assessment information between relevant specialist teams
Wider context from the report “I now write to the two Hospital Trusts and to the Croft House Rest Home to confirm that in my view action should be taken because there is a concern about the quality of the gathering and exchange of information between the various medical professionals involved in Mrs. Owens’s care for the following reasons:
1. A District Nurse was unaware of potentially important information as regards the Patient including how restricted her movement was.
2. Having considered all of the oral evidence in court and the clinical records, the amount and quality of the information provided to the hospital is limited and this had an impact upon later decisions taken and not least by the Tissue Viability Nurse once she was involved.
3. Although the District Nurse explained why she did not examine the Deceased’s left hip area on 21st November 2012, the Nurse in my view ought to have examined that area given the Patient was viewed as being at high risk of developing pressure areas. Such examination may have prompted her, given her professional experience, to recognise a pressure area as distinct from a burn / scald and that information may then have been communicated on to hospital staff who would have then most likely involved the Tissue Viability Nurse more quickly reducing the chances of an incorrect assumption being made that the hip area was problematic as a result of a pressure area and not due to burns inflicted on 2nd November 2012. However, having chosen not to do so this was not then communicated to other medical professionals involved in her care for them to assess.
4. That following arrival and assessment at the Royal Preston Hospital, that there was a lack of communication between the clinical team and the plastic surgery team , which appears to have contributed to the fact that it was not until 3rd December 2012 when the Tissue Viability Nurse became involved.
These issues as regards the gathering and exchange of information as regards this Patient raise concerns that an incorrect assumption – such as the one made that Mrs Owens hip area was damaged due to the incident involving the commode on 2nd November 2012 - may arise in a future case and with fatal consequences if such an incorrect assumption were not to be recognised early enough to positively affect a Patient’s outcome.
” Open source report
4 Nov 2014 Mark Bentley Hudson · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 1 Failure of Hospital Switchboard procedures to ensure follow-up of urgent specialist care requests 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
Mark Bentley Hudson · 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
Mark Bentley Hudson was admitted to hospital for chest pain, underwent urgent coronary artery bypass surgery, and later suffered cardiac arrests. During the second arrest, specialist assistance was delayed or may not have been contacted, and an oesophageal intubation went unrecognised; the concern was that procedures for urgent CICU requests via the switchboard were not sufficiently robust.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Hospital Switchboard procedures to ensure follow-up of urgent specialist care requests
Wider context from the report “Although encouraged by the steps that have been / are being taken internally at the Hospital further to this death, I remain concerned that there is a real risk that when the need arises for urgent provision of specialist care within the CICU department, such requests may go unanswered or be delayed . If CICU staff request such assistance via the Hospital Switchboard personnel at the hospital, I am concerned that the procedures in place are insufficiently robust to the extent that requests may not be followed up appropriately and to the potential detriment of the Patient requiring that urgent help.
” Open source report
29 Aug 2014 Linda Rose Lloyd · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2 Insufficient staffing resilience View source Insufficiently robust hospital procedures 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
Linda Rose Lloyd · 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
Linda Rose Lloyd was found at home after complaining of a headache and was taken to hospital, where she was assessed, underwent a CT scan confirming an acute subdural haemorrhage, and died on 3 January 2014. The report raised concerns that treatment was delayed and that hospital procedures and staffing levels were insufficiently robust to minimise the risk of similar deaths.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing resilience
Wider context from the report “However, having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because:
Although encouraged by the steps being taken, I remain concerned that the procedures in place at the hospital are insufficiently robust, and that staffing levels do not provide the Trust with sufficient resilience , to enable the Trust to minimise the risks of further deaths in similar circumstances particularly given the criticisms made by the independent expert and the number of areas of concern he raises.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust hospital procedures
Wider context from the report “However, having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because:
Although encouraged by the steps being taken, I remain concerned that the procedures in place at the hospital are insufficiently robust , and that staffing levels do not provide the Trust with sufficient resilience, to enable the Trust to minimise the risks of further deaths in similar circumstances particularly given the criticisms made by the independent expert and the number of areas of concern he raises.
” Open source report
17 Jun 2014 AUDREY VERA GARLAND · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure by the GP to examine the patient’s legs View source Failure to arrange District Nurse attendance to redress the legs View source Failure by the District Nursing service to treat necrotic ulcers appropriately View source Failure by the GP practice to recognise the severity of leg ulceration View source Failure by the District Nursing service to appreciate necrotic ulcers View source Failure to organise transport for hospital outpatient appointments View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
AUDREY VERA GARLAND · 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
Audrey Vera Garland developed worsening necrotic and gangrenous ulcers on her legs and feet, and her condition deteriorated until her death. The report identified concerns about failures to recognise and appropriately treat the ulceration, missed hospital appointments because transport was not organised, and inadequate assessment during a GP home visit.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by the GP to examine the patient’s legs
Wider context from the report “4. A home visit from the GP took place on the 12th September 2013 yet the doctor did not even examine the patient’s legs . He had not taken the simple expedient of arranging for a District Nurse to be in attendance to redress the legs.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange District Nurse attendance to redress the legs
Wider context from the report “4. A home visit from the GP took place on the 12th September 2013 yet the doctor did not even examine the patient’s legs. He had not taken the simple expedient of arranging for a District Nurse to be in attendance to redress the legs .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by the District Nursing service to treat necrotic ulcers appropriately
Wider context from the report “2. There was a failure by the District Nursing service to fully appreciate and treat appropriately the necrotic ulcers from which Mrs Garland was suffering.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by the GP practice to recognise the severity of leg ulceration
Wider context from the report “1. There was a failure by the GP practice to recognise or fully appreciate the severity of the ulceration to her legs .
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by the District Nursing service to appreciate necrotic ulcers
Wider context from the report “2. There was a failure by the District Nursing service to fully appreciate and treat appropriately the necrotic ulcers from which Mrs Garland was suffering.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to organise transport for hospital outpatient appointments
Wider context from the report “3. Despite the fact that she was considered to be in need of an outpatient appointment at Blackpool Hospital on two separate occasions, this did not take place because no-one organised transport for her to get to and from the hospital .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed joint wound-review visits with tissue-viability specialists and general practitioners for patients with deteriorating wounds.
Verbatim wording from the response “Any ulcer that fails to improve or deteriorates and there is an issue of noncompliance is highlighted using the organisation’s untoward incident system. Joint visits with other health care professionals such as the Specialist Tissue Viability Advisor and General Practitioners to review patients with deteriorating wounds are now embedded into practice within the team.” Source location 2014-0271-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve team referral processes for tissue-viability support in complex wound management.
Verbatim wording from the response “The team has an improved understanding of the referral processes to secure Tissue Viability Advisor support in relation to complex wound management. In line with best practice standards, the measurement of wounds and documenting progress or deterioration are now being monitored robustly by the team.” Source location 2014-0271-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate performance-management systems with accountability, joint visits, reflective practice and development plans for substandard clinical performance.
Verbatim wording from the response “Performance management systems are now in place with individuals being called to account when their clinical practice fails to meet the required standard. This includes joint visits, reflective practice” Source location 2014-0271-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor wound measurement and documentation of progress or deterioration against best-practice standards.
Verbatim wording from the response “The team has an improved understanding of the referral processes to secure Tissue Viability Advisor support in relation to complex wound management. In line with best practice standards, the measurement of wounds and documenting progress or deterioration are now being monitored robustly by the team.” Source location 2014-0271-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide daily rotational joint clinical supervision and focused senior-nurse support for leg-ulcer and wound-care management.
Verbatim wording from the response “Clinical supervision has been strengthened, specifically in relation to the management of leg ulcers. Supervision – in the form of joint visits with a senior nurse is happening daily on a rotational basis with individual members of the team. This is to support the changes in practice required and to ensure good practice is embedded. Individual nurses are also having more focused support by a senior nurse in the management of wound care and how to manage wound infection.” Source location 2014-0271-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct daily face-to-face clinical handovers identifying high-risk complex patients and required clinical actions.
Verbatim wording from the response “A daily face to face clinical handover of care is in place with high risk complex patients being identified and clinical discussions held in order that all members of the team are aware of the risks and the actions required to support good clinical care and improvement.” Source location 2014-0271-Response
Open published response
9 May 2014 Linda Yvonne Fisher · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 3 Failure to accurately determine patient weight for medication dosage View source Failure to communicate relevant family medical history effectively to hospital staff involved in care View source Failure to obtain relevant family medical history from patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Linda Yvonne Fisher · 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
Linda Yvonne Fisher was admitted to hospital with knee pain and was treated for a suspected deep vein thrombosis. She was found collapsed on 17 October 2013 and died from a pulmonary embolism. Concerns related to medication dosages being based on inaccurately assessed patient weight and relevant family medical history not being obtained and communicated effectively.
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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately determine patient weight for medication dosage
Wider context from the report “1. The inquest heard evidence that patients may be admitted to hospital who, once medically assessed, may require medication the dosage of which may be determined by the weight of that patient. On occasion such a patient may not be able to be weighed in order to determine their weight, perhaps for example due to a leg injury that prevents the patient bearing their own weight for long enough to allow medical staff to weigh them. In such circumstances, a Doctor placed reliance upon the Deceased’s own verbal assessment of her own weight and used this information to decide upon the medication dosage. Although I was informed that the Trust is aware of this issue and have considered one method of resolving it [which I understand is not to be implemented], I remain concerned that patients may be prescribed medications at a dosage which is inaccurately determined due to the fact that a patient has incorrectly assessed their own weight , and if patients do not receive the correct dosage future deaths may result.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant family medical history effectively to hospital staff involved in care
Wider context from the report “2. The inquest also heard evidence that other members of the Deceased’s family had suffered from a similar condition. There were no records to suggest that this relevant information had been obtained by medical staff following her admission, and therefore nor had it been communicated effectively to other staff who may in due course have had involvement in her care . I am concerned that if such information is not obtained appropriately from patients and is not communicated effectively to other hospital staff then decisions pertaining to clinical care may be made erroneously and future deaths may result.
” 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 Blackpool Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain relevant family medical history from patients
Wider context from the report “2. The inquest also heard evidence that other members of the Deceased’s family had suffered from a similar condition. There were no records to suggest that this relevant information had been obtained by medical staff following her admission, and therefore nor had it been communicated effectively to other staff who may in due course have had involvement in her care. I am concerned that if such information is not obtained appropriately from patients and is not communicated effectively to other hospital staff then decisions pertaining to clinical care may be made erroneously and future deaths may result.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Perform Mid Upper Arm Circumference calculations using MUST when patients cannot be weighed, to assist in establishing accurate weight.
Verbatim wording from the response “As you were advised at the inquest the Ward staff, now, in addition to obtaining verbal confirmation of a patients weight, if it is not possible to weigh the patient, a Mid Upper Arm Circumference calculation is performed (MUAC) in line with the malnutrition Universal Screening Tool (MUST) to assist in establishing an accurate weight.” Source location 2014-0226-Response-by-Blackpool-Teaching-Hospitals
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Familial history was obtained, and its absence at admission did not materially affect disease-risk assessment or treatment.
Verbatim wording from the response “2) That a familial history of disease was not recorded in the notes.” Source location 2014-0226-Response-by-Blackpool-Teaching-Hospitals
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Exact patient weight is not required for dalteparin dosage; verbal weight assessment is acceptable when physical weighing is not possible.
Verbatim wording from the response “1) That we may rely upon patient’s verbal assessment of their own weight to determine medication dosage.” Source location 2014-0226-Response-by-Blackpool-Teaching-Hospitals
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations