17 Dec 2021 JOAN WRIGHT · Prevention of Future Deaths report Manchester West
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Concerns raised 1 Insufficient availability, workability and accessibility of IT facilities for timely electronic record-keeping 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
JOAN WRIGHT · 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
Joan Wright, aged 91, fell at home, sustained a fractured left femur, and underwent surgery during which a guide wire penetrated her pelvis. She later developed a severe infection in the hip and died at a nursing home on 16 June 2021. The report raised concerns that insufficient workable and accessible IT facilities caused crucial clinical information to go unrecorded, creating a risk to other patients.
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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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability, workability and accessibility of IT facilities for timely electronic record-keeping
Wider context from the report “(1) Both the Divisional Review Report produced by the Trust and oral evidence at the inquest disclosed problems with insufficient workable IT facilities at the hospital to allow for timely record-keeping in patients' electronic notes . I was advised that all clinical staff are supposed to make records in the electronic notes and that no handwritten records are now kept. I heard evidence that staff therefore have to rely on memory, or notes written on scraps of paper, until such time as they can access the electronic records on a computer . This case provided several instances in the care of a single patient where either no notes were made at all of clinical discussions or management plans, or crucial information was omitted. I am concerned that the issues of availability, workability and accessibility of IT equipment for such recording (in the context of a reliance on paperless working) creates a risk of future deaths to other patients where crucial information may go unrecorded .
” 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 Trial additional computers on wheels to assess their effect on timely and accurate clinical documentation.
Verbatim wording from the response “Following feedback from clinical staff, around their challenges in accessing the EPR system and associated devices, a working group was established to understand this further. This led to a test trial, which ran throughout May and June 2021, and aimed to consider the impact of supplying two additional two computers on wheels to inpatient wards. Findings, clearly demonstrated the positive impact these additional devices had in supporting staff with inputting timely, and maintaining accurate clinical records.” Source location 2021-0420-Response-from-Royal-Bolton-Hospital_Published
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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 Review ward-round processes and competing demands for computers on wheels, then develop and implement relevant action plans.
Verbatim wording from the response “We acknowledge there have been pressures on IT equipment and the computers on wheels, in particular across the surgical wards, where there have been competing demands from the surgical teams and nursing staff. In addition to the extra equipment ordered, a Steering Group has been established to review ward round processes and the competing demands on the equipment by various clinical staff. The work being undertaken by the Steering Group is expected to be completed by May 2022 with relevant action plans developed and in place.” Source location 2021-0420-Response-from-Royal-Bolton-Hospital_Published
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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 Procure and deploy additional computers on wheels across all wards to improve access to electronic patient records.
Verbatim wording from the response “The results were presented to the Senior Nurse Management Team in July 2021 and the Divisional Nurse Directors confirmed the device requirements. In August 2021, Executive approval of the recommendations for additional computers was provided. Following this, in October 2021, a business case, outlining the plan for finance provision and information technology deployment, was approved by the Trusts Capital Revenue Investment Group.” Source location 2021-0420-Response-from-Royal-Bolton-Hospital_Published
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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 ward visits, educate clinical staff on equipment housekeeping, and audit equipment care, charging and fault reporting.
Verbatim wording from the response “In addition, following the scoping of existing devices on wards, the Technical Team found that poor care of the equipment and the delay in reporting damaged equipment to the Information Technology Department resulted in avoidable equipment unavailability.” Source location 2021-0420-Response-from-Royal-Bolton-Hospital_Published
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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 Deploy the electronic patient record system and associated devices across inpatient areas.
Verbatim wording from the response “The Electronic Patient Record (EPR) system was deployed to inpatient areas in October 2019. The devices were allocated based on learning from other organisations, workflows, number of beds, ward layout, EPR functionality and existing equipment. The devices included; mobile computer carts, fixed desktop computers, drug trolley laptops, tablets and ‘Patient Status at a Glance’ electronic ‘tracking boards’. This technology was approved by each of our Divisional Leadership Teams and through the governance of the Transformation Board prior to going live with the system.” Source location 2021-0420-Response-from-Royal-Bolton-Hospital_Published
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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 Equipment deployment was delayed by the global data-chip shortage affecting manufacturing and distribution.
Verbatim wording from the response “An order was placed with suppliers on the 11th November 2021 and since then there has been regular liaison with suppliers in order to secure the earliest available delivery of equipment. Due to the current global shortage of data silicon chips, which is severely affecting the manufacturing of technical equipment, this has delayed delivery of the order. The suppliers have provided a provisional delivery date of June 2022, however this is reliant upon no further delays within the manufacturing and distribution chain. Once the equipment has been delivered the Technical Team will prioritise resources to build and deploy the equipment across all wards, within seven to ten days.” Source location 2021-0420-Response-from-Royal-Bolton-Hospital_Published
Open published response
21 Aug 2018 Louie Francis Bradley · Prevention of Future Deaths report Manchester West
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Concerns raised 3 Unsafe advice to breastfeed in bed beside the baby when the mother is fatigued and alone View source Failure to properly complete standard Trust issue documentation with vital maternal information View source Failure to document advice given to 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
Louie Francis Bradley · 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
Louie Francis Bradley died following breastfeeding in bed with his mother, who fell asleep. Concerns included advice to breastfeed in bed while side-by-side with the baby when the mother was fatigued, and incomplete documentation of key information and advice given to the patient.
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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe advice to breastfeed in bed beside the baby when the mother is fatigued and alone
Wider context from the report “1. The midwives at your Hospital gave evidence that they still advise breastfeeding in bed whilst lying side-by-side with the baby even if no-one else is present and the mother is obviously fatigued , this leads to inadvertent co-sleeping and as in this case can lead to 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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly complete standard Trust issue documentation with vital maternal information
Wider context from the report “2. The standard Trust issue documentation was not (properly) completed with the omission of vital information such as mother’s name, GP Practice, address etc. ; similarly advice allegedly given to patient was not documented.
” 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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document advice given to patients
Wider context from the report “2. The standard Trust issue documentation was not (properly) completed with the omission of vital information such as mother’s name, GP Practice, address etc.; similarly advice allegedly given to patient was not documented .
” 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 Put relevant safe-sleeping documentation in place.
Verbatim wording from the response “I have attached an Action Plan which details a number of improvements together with the relevant documentation which is now in place for your reference. I hope that my response has provided you and the family with the assurance that the Trust has taken appropriate action regarding safe sleeping advice and documentation.” Source location 2018-0261-Response-by-Bolton-NHS-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 Request the Head of Midwifery, Divisional Nurse Director and Families Division Governance Lead to review safe-sleeping concerns.
Verbatim wording from the response “Following receipt of the Regulation 28 Report, I requested that the Head of Midwifery/Divisional Nurse Director and the Governance Lead for the Families Division review your concerns and would like to assure you that further actions in addition to the actions identified in the Serious Incident Report have been taken.” Source location 2018-0261-Response-by-Bolton-NHS-Trust
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20 Oct 2016 Colin Garth · Prevention of Future Deaths report Manchester West
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Concerns raised 4 Lack of written discharge guidance for monitoring, cleaning and flushing Hickman or central lines View source Failure to refer a faulty syringe driver for repair or replacement before reconnection View source Lack of staff knowledge of the policy for provision and use of Hickman or central lines View source Failure of syringe driver equipment to sound a fault alarm 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.
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AI-generated summary
Colin Garth · 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
Colin Garth was diagnosed with colon cancer on 5 May 2016, underwent surgery and Hickman line insertion, was readmitted on 18 June, and died at Royal Bolton Hospital on 19 June 2016. The medical cause of death included sepsis, Hickman line infection and pneumonia, and disseminated colonic carcinoma. Concerns included inadequate written guidance for patients discharged with Hickman or central lines, insufficient staff knowledge of relevant policy, and a syringe driver that failed to alarm when blocked and was reconnected rather than referred for repair or replacement.
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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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of written discharge guidance for monitoring, cleaning and flushing Hickman or central lines
Wider context from the report “A. During the course of the evidence I was told that when patients are discharged from the hospital with a Hickman or central line in situ, they are not furnished with any guidance booklet or sheet as to how the said line should be monitored, cleaned, flushed etc. It is clearly desirable that they should be as well informed as possible and I therefore consider that the provision of such written advice should be considered.
” 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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer a faulty syringe driver for repair or replacement before reconnection
Wider context from the report “C. In evidence I was told that at one point the syringe driver (or the extension from it) became blocked and ceased to deliver the fluid as intended by the doctors. This is a fault which can happen in the best of all worlds. What concerned me greatly, however, was that the machine did not sound any bleep or alarm to indicate that it was faulty and having cleared the blockage, the nurse then reconnected the same machine rather than referring it for repair/replacement . There was a very clear need for education of the staff as to how important it is to ensure that all machines are operating properly and safely.
” 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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of the policy for provision and use of Hickman or central lines
Wider context from the report “B. Whilst I was satisfied that the Trust does have a clear Policy as to the provision of and use of such lines, there was clearly a lack of knowledge of this policy even amongst quite senior staff members . There should be consideration given to a proper continuous programme of information and education for ALL 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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of syringe driver equipment to sound a fault alarm
Wider context from the report “C. In evidence I was told that at one point the syringe driver (or the extension from it) became blocked and ceased to deliver the fluid as intended by the doctors. This is a fault which can happen in the best of all worlds. What concerned me greatly, however, was that the machine did not sound any bleep or alarm to indicate that it was faulty and having cleared the blockage, the nurse then reconnected the same machine rather than referring it for repair/replacement. There was a very clear need for education of the staff as to how important it is to ensure that all machines are operating properly and safely.
” Open source report
30 Dec 2015 Mollie Bentham · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 5 Failure to record family concerns, clinical attendances and observed symptoms in patient notes View source Failure to document attendance, actions, assigned responsibility and timescales in Multi-Disciplinary Team Meeting notes View source Failure to conduct effective shift handovers between nursing and medical staff View source Inadequate training of nursing and medical staff in the above information-management processes View source Failure of nursing and medical staff to liaise about patient concerns and clinical attendances 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.
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AI-generated summary
Mollie Bentham · 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
Mollie Bentham died at Rivington View Nursing Home on 1 May 2015 after deteriorating following her transfer there from Darley Court Intermediate Care Centre. Concerns included failures to record and communicate family reports of abdominal pain, inadequate clinical review and documentation, absent or incomplete handovers, and insufficiently detailed multidisciplinary meeting records. The report identified risks to future patients, particularly those unable to communicate their symptoms.
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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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record family concerns, clinical attendances and observed symptoms in patient notes
Wider context from the report “1. During the Inquest evidence was heard that
i. The notes at Darley Court Intermediate Care Centre did not refer to the family concerns expressed to the nursing staff from the 23rd April 2015 onwards and the notes did not include a note from the out of hours General Practitioner, who attended Darley Court on the 26th April 2015, nor the attendance of ████████ on the 27th April 2015. The notes did not make any reference to abdominal pain suffered by Miss Bentham until the 28th April 2015, even though the family expressed concerns with regard to abdominal pain on the 23rd April 2015.
ii. There was no evidence of liaison between the nursing staff and the medical staff at Darley Court Intermediate Care Centre, particularly in relation to the concerns expressed by the family and with regard to the attendance of the out of hours General Practitioner on the 26th April 2015.
iii. There was no evidence of handovers at shift changes as between nursing staff and medical staff particularly in relation to the concerns expressed by the family and the attendance of the out of hours General Practitioner on the 26th April 2015.
iv. The notes of the Multi-Disciplinary Team Meetings, including the Meeting on the 27th April 2015, did not give details of who was present at the Meeting, the actions to be taken following the Meeting together with the person who was given responsibility to take the actions and a timescale in relation to the actions.
The above concerns are particularly relevant in relation to a patient, like Miss Bentham, who was unable to communicate with either nursing staff or medical staff. In such circumstances and in the absence of documented and noted information in relation to family concerns a condition suffered by the patient may be left untreated without consideration by a reviewing doctor or a Multi-Disciplinary Team Meeting.
v. The above issues raise training issues in relation to staff, both nursing and medical, at Darley Court Intermediate Care Centre.
vi. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues, particularly where known symptoms observed by the family are not brought to the attention of the reviewing medical team and no investigations are conducted with regard to the observed symptoms.
” 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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document attendance, actions, assigned responsibility and timescales in Multi-Disciplinary Team Meeting notes
Wider context from the report “1. During the Inquest evidence was heard that
i. The notes at Darley Court Intermediate Care Centre did not refer to the family concerns expressed to the nursing staff from the 23rd April 2015 onwards and the notes did not include a note from the out of hours General Practitioner, who attended Darley Court on the 26th April 2015, nor the attendance of ████████ on the 27th April 2015. The notes did not make any reference to abdominal pain suffered by Miss Bentham until the 28th April 2015, even though the family expressed concerns with regard to abdominal pain on the 23rd April 2015.
ii. There was no evidence of liaison between the nursing staff and the medical staff at Darley Court Intermediate Care Centre, particularly in relation to the concerns expressed by the family and with regard to the attendance of the out of hours General Practitioner on the 26th April 2015.
iii. There was no evidence of handovers at shift changes as between nursing staff and medical staff particularly in relation to the concerns expressed by the family and the attendance of the out of hours General Practitioner on the 26th April 2015.
iv. The notes of the Multi-Disciplinary Team Meetings, including the Meeting on the 27th April 2015, did not give details of who was present at the Meeting, the actions to be taken following the Meeting together with the person who was given responsibility to take the actions and a timescale in relation to the actions.
The above concerns are particularly relevant in relation to a patient, like Miss Bentham, who was unable to communicate with either nursing staff or medical staff. In such circumstances and in the absence of documented and noted information in relation to family concerns a condition suffered by the patient may be left untreated without consideration by a reviewing doctor or a Multi-Disciplinary Team Meeting.
v. The above issues raise training issues in relation to staff, both nursing and medical, at Darley Court Intermediate Care Centre.
vi. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues, particularly where known symptoms observed by the family are not brought to the attention of the reviewing medical team and no investigations are conducted with regard to the observed symptoms.
” 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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct effective shift handovers between nursing and medical staff
Wider context from the report “1. During the Inquest evidence was heard that
i. The notes at Darley Court Intermediate Care Centre did not refer to the family concerns expressed to the nursing staff from the 23rd April 2015 onwards and the notes did not include a note from the out of hours General Practitioner, who attended Darley Court on the 26th April 2015, nor the attendance of ████████ on the 27th April 2015. The notes did not make any reference to abdominal pain suffered by Miss Bentham until the 28th April 2015, even though the family expressed concerns with regard to abdominal pain on the 23rd April 2015.
ii. There was no evidence of liaison between the nursing staff and the medical staff at Darley Court Intermediate Care Centre, particularly in relation to the concerns expressed by the family and with regard to the attendance of the out of hours General Practitioner on the 26th April 2015.
iii. There was no evidence of handovers at shift changes as between nursing staff and medical staff particularly in relation to the concerns expressed by the family and the attendance of the out of hours General Practitioner on the 26th April 2015.
iv. The notes of the Multi-Disciplinary Team Meetings, including the Meeting on the 27th April 2015, did not give details of who was present at the Meeting, the actions to be taken following the Meeting together with the person who was given responsibility to take the actions and a timescale in relation to the actions.
The above concerns are particularly relevant in relation to a patient, like Miss Bentham, who was unable to communicate with either nursing staff or medical staff. In such circumstances and in the absence of documented and noted information in relation to family concerns a condition suffered by the patient may be left untreated without consideration by a reviewing doctor or a Multi-Disciplinary Team Meeting.
v. The above issues raise training issues in relation to staff, both nursing and medical, at Darley Court Intermediate Care Centre.
vi. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues, particularly where known symptoms observed by the family are not brought to the attention of the reviewing medical team and no investigations are conducted with regard to the observed symptoms.
” 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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of nursing and medical staff in the above information-management processes
Wider context from the report “1. During the Inquest evidence was heard that
i. The notes at Darley Court Intermediate Care Centre did not refer to the family concerns expressed to the nursing staff from the 23rd April 2015 onwards and the notes did not include a note from the out of hours General Practitioner, who attended Darley Court on the 26th April 2015, nor the attendance of ████████ on the 27th April 2015. The notes did not make any reference to abdominal pain suffered by Miss Bentham until the 28th April 2015, even though the family expressed concerns with regard to abdominal pain on the 23rd April 2015.
ii. There was no evidence of liaison between the nursing staff and the medical staff at Darley Court Intermediate Care Centre, particularly in relation to the concerns expressed by the family and with regard to the attendance of the out of hours General Practitioner on the 26th April 2015.
iii. There was no evidence of handovers at shift changes as between nursing staff and medical staff particularly in relation to the concerns expressed by the family and the attendance of the out of hours General Practitioner on the 26th April 2015.
iv. The notes of the Multi-Disciplinary Team Meetings, including the Meeting on the 27th April 2015, did not give details of who was present at the Meeting, the actions to be taken following the Meeting together with the person who was given responsibility to take the actions and a timescale in relation to the actions.
The above concerns are particularly relevant in relation to a patient, like Miss Bentham, who was unable to communicate with either nursing staff or medical staff. In such circumstances and in the absence of documented and noted information in relation to family concerns a condition suffered by the patient may be left untreated without consideration by a reviewing doctor or a Multi-Disciplinary Team Meeting.
v. The above issues raise training issues in relation to staff, both nursing and medical, at Darley Court Intermediate Care Centre.
vi. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues, particularly where known symptoms observed by the family are not brought to the attention of the reviewing medical team and no investigations are conducted with regard to the observed symptoms.
” 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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing and medical staff to liaise about patient concerns and clinical attendances
Wider context from the report “1. During the Inquest evidence was heard that
i. The notes at Darley Court Intermediate Care Centre did not refer to the family concerns expressed to the nursing staff from the 23rd April 2015 onwards and the notes did not include a note from the out of hours General Practitioner, who attended Darley Court on the 26th April 2015, nor the attendance of ████████ on the 27th April 2015. The notes did not make any reference to abdominal pain suffered by Miss Bentham until the 28th April 2015, even though the family expressed concerns with regard to abdominal pain on the 23rd April 2015.
ii. There was no evidence of liaison between the nursing staff and the medical staff at Darley Court Intermediate Care Centre, particularly in relation to the concerns expressed by the family and with regard to the attendance of the out of hours General Practitioner on the 26th April 2015.
iii. There was no evidence of handovers at shift changes as between nursing staff and medical staff particularly in relation to the concerns expressed by the family and the attendance of the out of hours General Practitioner on the 26th April 2015.
iv. The notes of the Multi-Disciplinary Team Meetings, including the Meeting on the 27th April 2015, did not give details of who was present at the Meeting, the actions to be taken following the Meeting together with the person who was given responsibility to take the actions and a timescale in relation to the actions.
The above concerns are particularly relevant in relation to a patient, like Miss Bentham, who was unable to communicate with either nursing staff or medical staff. In such circumstances and in the absence of documented and noted information in relation to family concerns a condition suffered by the patient may be left untreated without consideration by a reviewing doctor or a Multi-Disciplinary Team Meeting.
v. The above issues raise training issues in relation to staff, both nursing and medical, at Darley Court Intermediate Care Centre.
vi. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues, particularly where known symptoms observed by the family are not brought to the attention of the reviewing medical team and no investigations are conducted with regard to the observed symptoms.
” Open source report
10 Dec 2014 Patricia Edge · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to carry out blood tests to identify excessive paracetamol dosing View source Lack of review of paracetamol doses View source Failure of staff training and Trust procedures to prevent prescribing and dispensing excessive paracetamol doses 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
Patricia Edge · 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
Patricia Edge died at Royal Bolton Hospital on 20 July 2014 after bowel cancer, bowel obstruction and ischaemic bowel, with paracetamol liver toxicity also identified in the inquest conclusion. An excessive dose of paracetamol was prescribed and dispensed between 14 and 19 July 2014, and the report raised concerns about prescribing and dispensing procedures, review of the dose, and the absence of blood tests.
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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out blood tests to identify excessive paracetamol dosing
Wider context from the report “(3) The apparent failure to carry out blood tests between 14ᵗʰ and 19ᵗʰ July, which would have revealed/confirmed the possibility of the dose of paracetamol being excessive , again considering issues of training and procedures.
” 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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of review of paracetamol doses
Wider context from the report “(2) The apparent lack of any review of the paracetamol dose between 14ᵗʰ and 19ᵗʰ July 2014.
” 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 Bolton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff training and Trust procedures to prevent prescribing and dispensing excessive paracetamol doses
Wider context from the report “(1) The circumstances – including training of staff and Trust procedures - in which a patient could be prescribed and dispensed an excessive dose of paracetamol on the 14ᵗʰ July 2014.
” 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 Amend the Medicines Management e-learning module to reflect the improved paracetamol prescribing process and circulate the message continually to clinical staff.
Verbatim wording from the response “In addition, the Medicines Management e-learning module has been amended to reflect the improved process and ensure the message is continually circulated to clinical staff.” Source location 2014-0531-Response-by-Bolton-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 Review and revise paracetamol prescribing practice to require regular monitoring by the responsible clinical team.
Verbatim wording from the response “The Medical Devices Committee and the Medications Safety Group have worked closely to address these issues and the process for prescribing Paracetamol has been thoroughly reviewed. As a result the Trust has now revised its practice and this improvement will ensure that where patients are prescribed Paracetamol there will be regular monitoring by the clinical team responsible for the patient.” Source location 2014-0531-Response-by-Bolton-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 Distribute the SBAR safety communication to medical staff, wards and services using paracetamol, including through staff newsletters and bulletins.
Verbatim wording from the response “The attached SBAR (Situation, Background, Assessment and Recommendations) slide details the seven actions taken by the Trust and addresses the three concerns that you have raised. An SBAR is a quality improvement tool which has been adopted by the Trust and is being used as a mechanism to communicate critical information to relevant staff and foster a culture of patient safety.” Source location 2014-0531-Response-by-Bolton-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 All reasonably practicable steps have been taken to improve paracetamol prescribing and address the identified concerns.
Verbatim wording from the response “We are confident that the Trust has taken all reasonably practicable steps to improve the system of prescribing of Paracetamol in order to address your concerns and I do hope that my response has provided you with the assurance that you and the family are looking for. If you need any further information, or if I can be of any further assistance please do not hesitate to contact me.” Source location 2014-0531-Response-by-Bolton-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations