28 Oct 2025 Alan HORROCKS · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 3 Failure to document reasons for incomplete ward observations View source Insufficient nursing establishment for ward bed capacity View source Failure to complete ward observations in accordance with escalation guidance View source
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AI-generated summary
Alan HORROCKS · 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
Alan Horrocks was admitted to hospital on 19 February 2025 with a suspected stroke, later diagnosed as viral encephalitis. He deteriorated, developing a Hyperosmolar Hyperglycaemic State and an upper gastrointestinal haemorrhage, and died on 17 March 2025 after treatment was withdrawn. The hospital investigation identified that overnight observations were not completed in accordance with escalation guidance and raised concerns about increased ward capacity without a corresponding increase in nursing establishment, alongside gaps in the existing nursing establishment.
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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 Bradford Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document reasons for incomplete ward observations
Wider context from the report “Following Mr Horrocks death an investigation was undertaken by the hospital, the report in respect thereof being provided to the court late on the afternoon 22 October 2025. The hospital investigation identified inter alia that observations were not completed on the ward overnight on 14 March 2025 in accordance with escalation guidance with no documented reason . Whilst the evidence did not identify Mr Horrocks "baseline" NEWS score, evidence at the inquest hearing from consultants involved in Mr Horrocks care identified a NEWS score of 5 required further observations and possible escalation. Further, that it was likely that there was an ongoing deterioration from late on 14 march 2025 into 15 March 2025 which was only appreciated further observations were undertaken shortly before midday on 15 March 2025 identifying an increase in the NEWS score to 12. The evidence indicated however that in Mr Horrocks case, even if his deterioration had been identified sooner, on a balance of probabilities, it would not have avoided his death when it occurred.
The hospital investigation also identified that during this period the ward bed capacity had been increased from 27 to 33 beds owning to winter pressures with no corresponding change to the nursing establishment on the ward. Further, during this period there were gaps in the existing nursing establishment on the ward.
Whilst the hospital investigation had identified these matters, there were no recommendations that these were issues for wider learning or how, if at all, these issues were to be addressed.
” 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 Bradford Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing establishment for ward bed capacity
Wider context from the report “Following Mr Horrocks death an investigation was undertaken by the hospital, the report in respect thereof being provided to the court late on the afternoon 22 October 2025. The hospital investigation identified inter alia that observations were not completed on the ward overnight on 14 March 2025 in accordance with escalation guidance with no documented reason. Whilst the evidence did not identify Mr Horrocks "baseline" NEWS score, evidence at the inquest hearing from consultants involved in Mr Horrocks care identified a NEWS score of 5 required further observations and possible escalation. Further, that it was likely that there was an ongoing deterioration from late on 14 march 2025 into 15 March 2025 which was only appreciated further observations were undertaken shortly before midday on 15 March 2025 identifying an increase in the NEWS score to 12. The evidence indicated however that in Mr Horrocks case, even if his deterioration had been identified sooner, on a balance of probabilities, it would not have avoided his death when it occurred.
The hospital investigation also identified that during this period the ward bed capacity had been increased from 27 to 33 beds owning to winter pressures with no corresponding change to the nursing establishment on the ward . Further, during this period there were gaps in the existing nursing establishment on the ward .
Whilst the hospital investigation had identified these matters, there were no recommendations that these were issues for wider learning or how, if at all, these issues were to be addressed.
” 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 Bradford Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete ward observations in accordance with escalation guidance
Wider context from the report “Following Mr Horrocks death an investigation was undertaken by the hospital, the report in respect thereof being provided to the court late on the afternoon 22 October 2025. The hospital investigation identified inter alia that observations were not completed on the ward overnight on 14 March 2025 in accordance with escalation guidance with no documented reason. Whilst the evidence did not identify Mr Horrocks "baseline" NEWS score, evidence at the inquest hearing from consultants involved in Mr Horrocks care identified a NEWS score of 5 required further observations and possible escalation. Further, that it was likely that there was an ongoing deterioration from late on 14 march 2025 into 15 March 2025 which was only appreciated further observations were undertaken shortly before midday on 15 March 2025 identifying an increase in the NEWS score to 12. The evidence indicated however that in Mr Horrocks case, even if his deterioration had been identified sooner, on a balance of probabilities, it would not have avoided his death when it occurred.
The hospital investigation also identified that during this period the ward bed capacity had been increased from 27 to 33 beds owning to winter pressures with no corresponding change to the nursing establishment on the ward. Further, during this period there were gaps in the existing nursing establishment on the ward.
Whilst the hospital investigation had identified these matters, there were no recommendations that these were issues for wider learning or how, if at all, these issues were to be addressed.
” 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 Provide documented staff feedback and mandatory retraining on NEWS escalation requirements.
Verbatim wording from the response “Once the patient safety event was recorded actions included local informal investigation, documented feedback, and mandatory retraining on NEWS.” Source location Response from Bradford 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 Disseminate incident learning through ward safety huddles and the Sisters’ meeting.
Verbatim wording from the response “Lessons learned were shared through ward safety huddles at every handover for the week following the reporting of the incident in March 2025. Those in attendance at ward safety huddles are all ward nursing staff on that shift. They occur every morning and every night. To ensure embedding of the actions, the incident was discussed again by Matron at the Sisters’ meeting on 10th October 2025.” Source location Response from Bradford 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 Conduct weekly audits of patient observation charts and report the results to the Clinical Governance Committee.
Verbatim wording from the response “In addition, a weekly audit of 10 patient observation charts was commenced immediately following the incident being identified. No further omissions have been identified since implementation. Audit reports are retained for inspection. They are also reported to the Clinical Governance Committee.” Source location Response from Bradford Teaching Hospitals
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Staffing levels exceeded the planned ratios for Ward 6’s expanded bed capacity, which the Trust says ensured safe and appropriate care.
Verbatim wording from the response “On 14th March 2025 the ward operated with 33 beds. Every year the number of patients requiring hospital admission increases, particularly during periods of seasonal pressure. To manage this demand the Trust implements a Winter Escalation Plan that includes opening additional beds. On Ward 6 this involves opening an extra bay of six beds and allocating additional staff specifically for these patients. As a result the established staffing levels rise from five Registered Nurses and five Health Care Assistants, to six Registered Nurses and six Health Care Assistants per shift, ensuring safe and appropriate care for the expanded patient cohort.” Source location Response from Bradford Teaching Hospitals
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16 Nov 2021 Sharon Anne ROBINSON · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 1 Failure to act on patients' antibiotic sensitivity 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.
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AI-generated summary
Sharon Anne ROBINSON · 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
Sharon Robinson died at Airedale Hospital on 7 February 2019 after an antibiotic administered on 27 January induced an anaphylactic reaction. The principal concern was that a possible patient sensitivity to an antibiotic might be disregarded and the antibiotic given despite that risk.
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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 Bradford Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on patients' antibiotic sensitivity
Wider context from the report “There is a concern that when a patient may have a sensitive to anti-biotic despite the low risk, this will be ignored and anti-biotic be given in any event .
” Open source report
9 Apr 2020 Allison Louise Bird · Prevention of Future Deaths report West Yorkshire (west)
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Concerns raised 3 Failure to escalate monitoring of patients’ vital signs View source Failure to consistently seek clinical review following non-reassuring vital signs results View source Failure to provide adequate preoperative discussion and explanation before consent 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.
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AI-generated summary
Allison Louise Bird · 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
Allison Louise Bird developed a gastro-pulmonary fistula, a recognised but rare complication of bariatric surgery, followed by severe infection and further surgery. Her condition deteriorated after surgery, she underwent emergency surgery on 13 March 2018, and she died on 16 March 2018 despite intensive care support. Concerns included the timing and adequacy of preoperative discussion and consent, monitoring of vital signs, and escalation for clinical review when observations were non-reassuring.
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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 Bradford Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate monitoring of patients’ vital signs
Wider context from the report “2. There did not appear to be an escalation of monitoring of Allison’s vital signs by nursing staff in the 24 hour period commencing at 11.00am on 12th March 2018.
” 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 Bradford Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently seek clinical review following non-reassuring vital signs results
Wider context from the report “3. Nursing staff did not appear to be consistently seeking clinical review following non reassuring vital signs results actually taken in the same 24 hour period referred to in 2 above.
” 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 Bradford Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate preoperative discussion and explanation before consent
Wider context from the report “1. There was no discussion/explanation provided to Allison before she underwent planned major thoracic surgery on the 5th March 2018, the explanation given was immediately before she was asked to provide her written consent in the theatre area minutes before surgery commenced , a situation which if repeated causes me concern for a patient being able to appropriately consider the risks associated with proposed surgery and determine if they are willing to consent .
” Open source report
1 Oct 2018 Michael Christopher Hopkins · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 1 Failure to ensure discharge information addresses thromboembolism risk after trauma-related surgery 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
Michael Christopher Hopkins · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Christopher Hopkins sustained a right patella fracture requiring surgery and was discharged from hospital. He later collapsed at home and died from a pulmonary thromboembolism, and the report raised a concern about information given at discharge to patients at risk of thromboembolism after surgery for trauma.
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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 Bradford Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure discharge information addresses thromboembolism risk after trauma-related surgery
Wider context from the report “To review current practice guidelines with respect to the information provided to patients on discharge from hospital that may be at risk of the formation of thromboembolisms given they have had recent surgery after sustaining a trauma .
” 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 Develop a revised leaflet for patients following blood-clot risk assessment.
Verbatim wording from the response “The Foundation Trust has been working hard to ensure that all eligible patients receive an assessment of their risk of developing blood clots, and can demonstrate consistent compliance with the relevant key performance indicators. Since the Regulation Report was received, we have reviewed the information provided to all patients (not just those who have experienced a trauma), following that assessment of risk, and as a result, the Trust has developed a revised leaflet that all patients will receive. I have attached an example of the leaflet to this letter, and confirm this leaflet will be introduced from the 1st December 2018.” Source location 2018-0331-Response-by-Bradford-Teaching-Hospital-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 Review patient information provided after blood-clot risk assessment.
Verbatim wording from the response “The Foundation Trust has been working hard to ensure that all eligible patients receive an assessment of their risk of developing blood clots, and can demonstrate consistent compliance with the relevant key performance indicators. Since the Regulation Report was received, we have reviewed the information provided to all patients (not just those who have experienced a trauma), following that assessment of risk, and as a result, the Trust has developed a revised leaflet that all patients will receive. I have attached an example of the leaflet to this letter, and confirm this leaflet will be introduced from the 1st December 2018.” Source location 2018-0331-Response-by-Bradford-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 the revised leaflet for all patients from 1 December 2018.
Verbatim wording from the response “The Foundation Trust has been working hard to ensure that all eligible patients receive an assessment of their risk of developing blood clots, and can demonstrate consistent compliance with the relevant key performance indicators. Since the Regulation Report was received, we have reviewed the information provided to all patients (not just those who have experienced a trauma), following that assessment of risk, and as a result, the Trust has developed a revised leaflet that all patients will receive. I have attached an example of the leaflet to this letter, and confirm this leaflet will be introduced from the 1st December 2018.” Source location 2018-0331-Response-by-Bradford-Teaching-Hospital-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