12 Nov 2024 Lisa Gale · Prevention of Future Deaths report Avon
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Concerns raised 2 Failure of urgent liver function test reporting thresholds to account for pregnancy-specific conditions View source Failure to communicate grossly abnormal liver function test results from laboratory staff to clinical staff View source
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AI-generated summary
Lisa Gale · 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
Lisa Gale developed Acute Fatty Liver of Pregnancy (AFLP) and later died despite hospital treatment and intensive care. The report raises concerns that markedly abnormal liver-function results were not urgently communicated because reporting thresholds did not account for pregnancy-specific conditions, resulting in a delay in diagnosing AFLP and starting appropriate treatment.
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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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of urgent liver function test reporting thresholds to account for pregnancy-specific conditions
Wider context from the report “(1) Blood was taken for liver function tests (LFTs) on admission before her condition was diagnosed;
(2) Lisa’s LFT’s were grossly elevated (normal range in brackets) – ALT 612 (10-50), bilirubin 122 (<21), creatine 168 (45-84);
(3) This was due to a potentially fatal condition – Acute Fatty Liver of Pregnancy – from which she subsequently died;
(3) Despite being grossly elevated, the results once obtained in the laboratory were not phoned through by the laboratory staff to the clinical staff;
(4) This was because the Royal College of Pathologists’ guidelines for urgent reporting only provides for the same with levels above 750 for ALT, 300 for bilirubin and 354 for creatinine – and does not provide for different reporting levels for those taken in pregnant women ;
(5) This is despite pregnancy specific conditions such as AFLP being potentially fatal at much lower levels of abnormal LFTs than those set currently by the Royal College of Pathologists ;
(4) As a result there was a delay in diagnosing her AFLP and starting appropriate treatment.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate grossly abnormal liver function test results from laboratory staff to clinical staff
Wider context from the report “(1) Blood was taken for liver function tests (LFTs) on admission before her condition was diagnosed;
(2) Lisa’s LFT’s were grossly elevated (normal range in brackets) – ALT 612 (10-50), bilirubin 122 (<21), creatine 168 (45-84);
(3) This was due to a potentially fatal condition – Acute Fatty Liver of Pregnancy – from which she subsequently died;
(3) Despite being grossly elevated, the results once obtained in the laboratory were not phoned through by the laboratory staff to the clinical staff ;
(4) This was because the Royal College of Pathologists’ guidelines for urgent reporting only provides for the same with levels above 750 for ALT, 300 for bilirubin and 354 for creatinine – and does not provide for different reporting levels for those taken in pregnant women;
(5) This is despite pregnancy specific conditions such as AFLP being potentially fatal at much lower levels of abnormal LFTs than those set currently by the Royal College of Pathologists;
(4) As a result there was a delay in diagnosing her AFLP and starting appropriate treatment.
” 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 Request that the Royal Colleges consider the report and develop national guidance on urgent LFT reporting reference ranges in pregnancy.
Verbatim wording from the response “To safely implement any recommended changes to reference ranges for LFTs in pregnancy we would ordinarily consider national guidance from the Royal Colleges. We have therefore written to both the Royal College of Pathologists and the Royal College of Obstetricians asking them to” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 Raise the issue with the regional obstetric lead for liaison with the national obstetric lead.
Verbatim wording from the response “At the time of writing, we are awaiting the response from the Royal College of Obstetricians. In the meantime, we have also raised the issue with the regional obstetric lead, who we understand is liaising with the national obstetric lead on this issue.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 Set up a task and finish group to implement nationally recommended urgent LFT reporting reference ranges safely across the Trust.
Verbatim wording from the response “Once national guidance has become available regarding a recommended reference range for urgent reporting of LFTs in pregnancy, UHBW will set up a task and finish group, led by Dr Bennett, Dr Willis, and Dr Liebling to implement these across the Trust in a safe and robust manner.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 The Royal Colleges are asked to consider and develop national guidance on urgent LFT reference ranges in pregnancy.
Verbatim wording from the response “To safely implement any recommended changes to reference ranges for LFTs in pregnancy we would ordinarily consider national guidance from the Royal Colleges. We have therefore written to both the Royal College of Pathologists and the Royal College of Obstetricians asking them to” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 Changing urgent LFT reference ranges in one Trust alone may create risk through inconsistent guidance and would not address the national issue.
Verbatim wording from the response “We have carefully considered the issue of setting a lower threshold for the urgent reporting reference range for Liver Function Tests (LFTs) in pregnant women. On reflection, we consider that one hospital Trust changing the reference range in isolation will not address the broader issue which has the potential to affect all pregnant women at a national level. UHBW is a tertiary level referral hospital, treating women from across the South-West region. We are concerned that developing guidance in respect of reference ranges for LFTs in pregnant women in UHBW in isolation, could potentially create more risk to patients rather than reduce it, as hospitals within the region, and across the country, would be working to different guidance.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
Open published response
Concerns raised 3 Lack of a system requiring radiologists to alert clinicians to inconsistencies before finalising their reports View source Lack of a system requiring radiologists to investigate inconsistencies in the site of injury between images View source Lack of a system requiring radiographers to ensure that pre-exposure markers are present in the x-ray field View source
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AI-generated summary
Gillian Baumgardt · 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
Gillian Baumgardt, an elderly woman with dementia, fractured her right hip but errors in performing and reporting the x-ray led to wrong-site surgery on her healthy left hip. She underwent surgery on the right fractured hip two days later and died six weeks later, having never regained her mobility; the report found that the wrong-site surgery contributed to her death. Concerns included the absence of systems requiring pre-exposure markers and the investigation of inconsistencies between images and the injury site before radiology reports were finalised.
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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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system requiring radiologists to alert clinicians to inconsistencies before finalising their reports
Wider context from the report “(1)Accurate radiology is essential to avoid wrong site surgery in elderly patients with dementia suffering hip fracture;
(2) There is no system requiring radiographers to ensure that pre-exposure markers are present in the x-ray field in all such patients;
(3) There is no system requiring radiologists to investigate inconsistency in the site of injury between different images and to alert clinicians to the inconsistency before finalising their report in all such patients.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system requiring radiologists to investigate inconsistencies in the site of injury between images
Wider context from the report “(1)Accurate radiology is essential to avoid wrong site surgery in elderly patients with dementia suffering hip fracture;
(2) There is no system requiring radiographers to ensure that pre-exposure markers are present in the x-ray field in all such patients;
(3) There is no system requiring radiologists to investigate inconsistency in the site of injury between different images and to alert clinicians to the inconsistency before finalising their report in all such patients.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system requiring radiographers to ensure that pre-exposure markers are present in the x-ray field
Wider context from the report “(1)Accurate radiology is essential to avoid wrong site surgery in elderly patients with dementia suffering hip fracture;
(2) There is no system requiring radiographers to ensure that pre-exposure markers are present in the x-ray field in all such patients ;
(3) There is no system requiring radiologists to investigate inconsistency in the site of injury between different images and to alert clinicians to the inconsistency before finalising their report in all such patients.
” 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 a discrepancy-management procedure requiring senior radiographer checks, clinician notification when unresolved, and documentation of communications or corrections in reports.
Verbatim wording from the response “Following the Regulation 28 Prevention of Future Deaths Report in respect of Mrs Baumgardt, there has been a full review carried out of how we manage a discrepancy in radiographic presentation, and/or side marking. We have already put forward a number of changes to practice, which will now go through our governance sign off prior to them being fully rolled out. These changes are due to be signed off at the Imaging Governance Committee scheduled for 18 June 2024.” Source location Response from North Bristol NHS Trust
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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 Audit trauma hip radiographs daily, challenge non-compliance, and provide feedback to improve marker accuracy and pre-exposure marker use.
Verbatim wording from the response “In addition, we have introduced a daily audit for the checking of trauma hip radiographs (in combination with the existing wider departmental audit of pre-exposure markers) providing a real focus on X-Ray Imaging for this patient group and presenting the opportunity to intervene should errors be noted and provide timely feedback for improvement when non-compliance is detected. Lead Radiographer Paul Hockling commenced this audit on 4 March 2024. Since then, this audit has evaluated over 1700 hip X-Ray images, all of which have been accurate in positioning, all with an anatomical marker, and an associated compliance rate of 95% for pre-exposure marker use. If there have been instances of non-compliance, these have been actively challenged with the Radiographers involved in order to bring about future quality improvement.” Source location Response from North Bristol NHS Trust
Open published response
15 Nov 2023 Calogero Di Blasi · Prevention of Future Deaths report Avon
View report summary
Concerns raised 3 Failure of specialty teams to communicate investigation information and share results in a timely manner View source Failure of 2-week urgent cancer pathway timeframes to include investigation reporting and referring-clinician review View source Insufficient breadth of endoscopist training for recognition of less frequently occurring lesions View source
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AI-generated summary
Calogero Di Blasi · 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
Calogero Di Blasi was referred for possible stomach and bowel cancer and underwent investigations including endoscopies and a CT scan. During a further endoscopy, a gastric varix was mistaken for an abnormal area and biopsied, causing a massive bleed; he died on 1 December 2022. The concerns included communication failures between specialist teams, insufficient timeframes for reviewing investigations on the urgent cancer pathway, and limitations in endoscopist training for recognising less common lesions.
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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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of specialty teams to communicate investigation information and share results in a timely manner
Wider context from the report “(1) That one of the teams caring for Mr Di Blasi was completely unaware of the input from another specialty team , despite both referrals being made under the 2-week urgent referral pathway. The lack of communication between these teams meant that timely sharing of results did not occur . Even the very knowledge of the fact that a CT scan had taken place would have alerted the endoscopist to check those results, and it is likely that the second endoscopy would not have gone ahead. I understand this to be a national issue and is likely to apply to other investigations being carried out.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of 2-week urgent cancer pathway timeframes to include investigation reporting and referring-clinician review
Wider context from the report “(2) That the reporting timeframes on the 2-week urgent cancer pathway referral does not take into account timeframes for reporting investigative procedures or subsequent review by the referring clinicians .
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient breadth of endoscopist training for recognition of less frequently occurring lesions
Wider context from the report “(3) The current training for Endoscopists for JAG certification requires the performance of 200 endoscopies. However, these tend to focus on the clinician’s area of specialty and therefore there is a danger that lesion recognition will be limited and insufficient to ensure that endoscopists are able to recognise less frequently occurring lesions . With the need for an increasing number of endoscopists, action should be taken.
” 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 locum radiology cover and additional reporting sessions for existing radiologists.
Verbatim wording from the response “Regrettably, in parallel with a number of organisations across the country, the Trust is not meeting this timeframe. The following mitigations have been put in place:” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 Launch a joint digital strategy to converge provider-collaborative IT systems and centralise clinical information digitally.
Verbatim wording from the response “UHBW and NBT will shortly appoint a joint Chief Executive and Chair. The Chief Digital Information Officer has already been appointed across both Trusts and is in the process of launching a Digital Strategy, with the aim of converging the IT systems across the provider collaborative.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 Add radiology turnaround times to the divisional risk register.
Verbatim wording from the response “All of the above actions will increase reporting capacity and seek to enact the recommendations from the national guidance. In addition, the Radiology team have added a risk to the risk register around turnaround times. This will ensure that this remains a priority for the Division.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 Collaborate with SWETA to create a mandatory local gastrointestinal endoscopy learning resource for statutory training.
Verbatim wording from the response “• Endoscopists have access to an online endoscopy learning platform (GIEQs online; accredited by the European Society for Gastrointestinal Endoscopy (ESGE) and American Society for Gastrointestinal Endoscopy (ASGE)). We are able to audit uptake of the online content prior to quarterly EUG meetings. We are also collaborating with the South-West Endoscopy Training Academy (SWETA) to create a mandatory local learning resource that will form a part of the Trust statutory training for staff involved in gastrointestinal endoscopy.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 Recruit radiologists to fill vacancies and increase reporting capacity.
Verbatim wording from the response “Regrettably, in parallel with a number of organisations across the country, the Trust is not meeting this timeframe. The following mitigations have been put in place:” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 Use outsourced radiology reporting to maximise reports completed within the target timeframe.
Verbatim wording from the response “Regrettably, in parallel with a number of organisations across the country, the Trust is not meeting this timeframe. The following mitigations have been put in place:” Source location Response from University Hospitals Bristol and Weston 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 Provide recurring endoscopy training lists, fellow placements and cross-institutional JAG-certified courses covering broader lesion recognition and pathology.
Verbatim wording from the response “The Trust has taken further action, over and above those completed for the PSII, to address this concern:” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 Scope increased radiographer resource to support radiologists.
Verbatim wording from the response “• The Division is undertaking a scoping exercise to increase the resource of radiographers who could support the radiologists.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 Scope administrative review of patient lists to identify parallel clinical pathways before endoscopy and assess a possible pilot.
Verbatim wording from the response “I asked ████████ and the witnesses to consider whether any further action could be taken to strengthen the pre-procedure checklist. I am advised that they have identified an additional potential change in practice. The Division of Surgery will undertake a scoping exercise to assess the feasibility of the administrative teams reviewing the patient list and identifying any patients who are on a parallel clinical pathway. The endoscopist would then be notified to review the electronic records and ICE and any relevant investigations before the procedure. Upon completion of the scoping exercise, the Division will consider whether a pilot may be offered for the endoscopy team.” Source location Response from University Hospitals Bristol and Weston 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 Provide accredited online endoscopy learning and audit uptake before quarterly endoscopy users’ meetings.
Verbatim wording from the response “• Endoscopists have access to an online endoscopy learning platform (GIEQs online; accredited by the European Society for Gastrointestinal Endoscopy (ESGE) and American Society for Gastrointestinal Endoscopy (ASGE)). We are able to audit uptake of the online content prior to quarterly EUG meetings. We are also collaborating with the South-West Endoscopy Training Academy (SWETA) to create a mandatory local learning resource that will form a part of the Trust statutory training for staff involved in gastrointestinal endoscopy.” Source location Response from University Hospitals Bristol and Weston 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 Discontinue paper radiology reports from 1 May 2024.
Verbatim wording from the response “Aligned to this, I have received an update in respect of the paper reports for radiology; these will be discontinued from 1 May 2024. Results will continue to be available via the ICE and PACS electronic reporting systems. As part of the transition away from paper results, the Trust plans to set up specialty specific reporting systems within our existing digital platforms.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 Set up specialty-specific radiology reporting systems within existing digital platforms.
Verbatim wording from the response “Aligned to this, I have received an update in respect of the paper reports for radiology; these will be discontinued from 1 May 2024. Results will continue to be available via the ICE and PACS electronic reporting systems. As part of the transition away from paper results, the Trust plans to set up specialty specific reporting systems within our existing digital platforms.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 Existing clinician checks provide a robust process for identifying relevant investigations for patients on parallel clinical pathways.
Verbatim wording from the response “As many patients are treated out of the region or in private or satellite institutions, the subsequent check by the clinician, through a discussion with the patient, provides another opportunity to identify relevant investigations, thereby ensuring there is a robust process in place.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 Radiology reporting cannot consistently meet the three-day cancer-pathway timeframe because of national staffing shortages, despite mitigation measures.
Verbatim wording from the response “As you heard in evidence, there is, regrettably, a national shortage of Radiologists. I therefore envisage that the Secretary of State for Health may wish to add to the below response from the Trust.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
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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 The Royal College of Physicians and its Joint Advisory Group on GI Endoscopy are responsible for responding nationally to endoscopist training concerns.
Verbatim wording from the response “3) The current training for Endoscopists for JAG accreditation requires the performance of 200 endoscopies. However, these tend to focus on clinician’s area of specialty and therefore there is danger that lesion recognition will be limited and insufficient to ensure that endoscopies are able to recognise less frequently occurring lesions. With the need for an increasing number of endoscopists, action should be taken.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
Open published response
Concerns raised 2 Serious deficiencies affecting patient safety at Southmead Hospital, Bristol View source Failure to ensure training of current staff and ongoing training for new staff 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
Ms. Madeleine Lawrence · 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
Ms. Madeleine Lawrence suffered a traumatic hip dislocation while playing rugby and later developed sepsis and necrotising myositis after her hospital admission. Her condition deteriorated, but observations were not performed or escalated in a timely manner, and prompt treatment for presumed sepsis was not initiated; she died in hospital on 25 March 2022. The concerns identified included serious deficiencies affecting patient safety and the adequacy of staff training on recognising and treating deteriorating patients and sepsis.
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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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Serious deficiencies affecting patient safety at Southmead Hospital, Bristol
Wider context from the report “(1) That serious deficiencies affecting the safety of patients at Southmead Hospital, Bristol which had been identified following the death of Ms. Lawrence
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure training of current staff and ongoing training for new staff
Wider context from the report “(2) The CQC should confirm that it is now satisfied that the Trust has addressed the training of current staff and has in place appropriate measures to ensure ongoing training for new staff .
” Open source report
Concerns raised 2 Failure to integrate the Summary Care Record with SMH and primary care electronic patient records for automatic transfer of clinical information View source Lack of routine and easy access to patients’ Summary Care Records for SMH clinical staff 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
Stephen William Cassidy · 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
Stephen William Cassidy fractured his hip and was admitted to Southmead Hospital, where he was given intravenous Ceftriaxone during anaesthetic induction despite a recorded Ceftriaxone allergy. He suffered a severe anaphylactic reaction and died shortly afterwards. The principal concern was that hospital staff could not routinely or easily access or automatically receive Summary Care Record information, including allergies, creating a risk of avoidable patient harm and 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to integrate the Summary Care Record with SMH and primary care electronic patient records for automatic transfer of clinical information
Wider context from the report “a) There is no provision for clinical staff at SMH to access patients’ Summary Care Record routinely or easily;
b) This is despite provision existing for SWAS clinical staff to do so before a patient arrives at hospital;
c) There is no provision for the Summary Care Record to be integrated with SMH’s hospital electronic patient record (known as Careflow/Connect) or the primary care electronic patient record (known as EMIS – Egton Medical Information System) – such that the Ceftriaxone allergy automatically appears in SMH’s electronic patient record ;
d) As a result hospital doctors are ignorant of important clinical information on the patients they are treating;
e) This can lead to avoidable patient harm including 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of routine and easy access to patients’ Summary Care Records for SMH clinical staff
Wider context from the report “a) There is no provision for clinical staff at SMH to access patients’ Summary Care Record routinely or easily ;
b) This is despite provision existing for SWAS clinical staff to do so before a patient arrives at hospital;
c) There is no provision for the Summary Care Record to be integrated with SMH’s hospital electronic patient record (known as Careflow/Connect) or the primary care electronic patient record (known as EMIS – Egton Medical Information System) – such that the Ceftriaxone allergy automatically appears in SMH’s electronic patient record;
d) As a result hospital doctors are ignorant of important clinical information on the patients they are treating;
e) This can lead to avoidable patient harm including death.
” Open source report
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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 Develop in-context NCRS integration with Careflow through coordinated NHSE, NBT and System C work.
Verbatim wording from the response “2. One-click/in-context access to NCRS: The ability to access the SCR (and its follower NCRS) in context unfortunately could not be deployed in 2022 at the time of the move to Careflow owing to technical incompatibilities. Following discussions, the IT teams of NHSE, NBT, and System C (producers of Careflow) have had a meeting on the 6th of November to agree a way forward on integration, and the Director of IT at NBT has communicated the requirement to System C so” Source location Response from NHS North Bristol NHS Trust
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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 Work with the ICB and Connecting Care team to provide clearer guidance when Connecting Care cannot display patient information.
Verbatim wording from the response “4. We have worked closely with the ICB and the Connecting Care team, they have updated their system to provide clearer advice if Connecting Care is unable to reflect the information contained in the NCRS/SCR/EMIS to "Connecting Care cannot display information on this patient at this time. PLEASE access this information from the National Summary Care Record (NCRS) by accessing the NHS Spine Portal".” Source location Response from NHS North Bristol NHS Trust
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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 Deploy non-smartcard NCRS access to all Trust staff after limited clinical deployment.
Verbatim wording from the response “1. Non-smartcard-based access to NCRS (National Care Record Service): Following discussions with NHSE, NBT IT team have explored access to the new NCRS with existing authentication protocols without having to use Smartcards. This has already been trialled successfully for a pilot cohort, and after a planned limited clinical deployment we would be in a position to make access available to all Trust staff in the first quarter of 2024. This would allow staff to access the NCRS from any browser by using the Microsoft authenticator app and without having to use a Smartcard.” Source location Response from NHS North Bristol NHS Trust
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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 Trial non-smartcard NCRS access with a pilot cohort.
Verbatim wording from the response “1. Non-smartcard-based access to NCRS (National Care Record Service): Following discussions with NHSE, NBT IT team have explored access to the new NCRS with existing authentication protocols without having to use Smartcards. This has already been trialled successfully for a pilot cohort, and after a planned limited clinical deployment we would be in a position to make access available to all Trust staff in the first quarter of 2024. This would allow staff to access the NCRS from any browser by using the Microsoft authenticator app and without having to use a Smartcard.” Source location Response from NHS North Bristol NHS Trust
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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 NHSE is best placed to address seamless integration of electronic patient record systems across England.
Verbatim wording from the response “We have addressed the progress towards integration of SCR/NCRS in-context in a) 2. The ability to populate alerts across systems was discussed in meetings with NHSE in October, however these poses significant logistical challenges in definition of data points and creation a ‘single source of truth’ across systems. NHSE are aware of the challenges faced and will be best placed to address the specific question of ‘seamless integration’ of EPR systems across England spanning primary and secondary care.” Source location Response from NHS North Bristol NHS Trust
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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 Smartcard use remains frequent, making Summary Care Record information visible to clinicians upon request.
Verbatim wording from the response “3. Smartcard use in NBT: The majority of NBT staff have active Smartcards even though they are not required for access to Careflow EPR. Following the issue of the Trust safety alert in April 2023 which encouraged staff to access the NCRS/SCR we requested NHSE to investigate access requests and they could confirm that the NCRS was accessed 3,810 times and SCR 2,787 times from NBT since 17th April 2023, with 473 access events for NCRS in the week of 23 October 2023. In the same week the SCR (which can only be accessed with a Smartcard) was accessed 356 times. NHSE were further able to confirm that in the 12 months leading up to October 2023 SCR was accessed from NBT using Smartcards on 30,247 occasions.” Source location Response from NHS North Bristol NHS Trust
Open published response
8 Sep 2023 Ms Cherry Lynne GARLAND · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Insufficient pharmacist capacity and medicines reconciliation checking View source Failure of hospital medication systems to exchange information, requiring manual transcription during ICU transfers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ms Cherry Lynne 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
Ms Cherry Lynne GARLAND died on 11 October 2022 in the Bristol Royal Infirmary from sepsis and right-sided heart failure after cardiac treatment, vascular injury, Covid and pneumonia. During her transfer from the Cardiac High Dependency Unit to the Cardiac Ward, a transcription error omitted antibiotics from her medication list, although the evidence accepted was that discontinuing them would have been reasonable at that time. The report raises concern that incompatible medication systems, manual transcription and insufficient pharmacist capacity create a known risk of future medication errors and 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient pharmacist capacity and medicines reconciliation checking
Wider context from the report “My concerns
• I heard evidence from an ICU Consultant (who I found to be both a reliable and an impressive witness), who told me, among other things, that:
- “... Transcription errors have always been a problem…” the ideal way to get rid of them would be to have a system [in the rest of the hospital] that speaks to ours
- The ICU retains lists of its patients’ medication on a computerised/electronic system
- The rest of the wards in the hospital do not operate the same system
- The available systems do not speak to each other (to put it in somewhat colloquial terms)
- Efforts to address that problem have proved fruitless
- As a result, every time an inpatient moves from ICU to another department in the hospital, an appropriately qualified member of staff has to physically transcribe that patient’s medication list
- With (for instance) 10 patients moving per day, 15-20 medications per patient, and multiple elements for each medication (name; dose; timing; indication; start date; signature etc.), “at a conservative estimate 1,500 to 2,000 elements [are transcribed daily]”
(Coroner’s comment: for obvious reasons this creates enormous potential for human error)
- There are a limited number of people who can prescribe (and are therefore able to perform this task); in critical care they are the same people who are responsible for providing care
- “We really need a second check… funding for more pharmacists… as a Trust we’re falling short of ICU national standards for years in terms of the number of pharmacists per bed and medicines reconciliation ”
- “I spoke to the Chief Pharmaceutical Officer – he has submitted 5 proposals in the last 7 years to try to get the deficit funded… [without success] ”
In summary, my view is that the circumstances currently in place create a very real (and known) risk that transcription errors will continue to occur. This in turn endangers patients, and creates a risk that people will die in the future as a result of such errors.
It is, sadly, very easy to envisage circumstances in which a patient might not receive essential medication at all, might receive the wrong dose of the medication they need, or might receive the wrong medication altogether, because of a transcription error.
In my opinion there is a risk that future deaths will occur unless action is taken, and in the circumstances it is my statutory duty to report to you.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital medication systems to exchange information, requiring manual transcription during ICU transfers
Wider context from the report “My concerns
• I heard evidence from an ICU Consultant (who I found to be both a reliable and an impressive witness), who told me, among other things, that:
- “... Transcription errors have always been a problem…” the ideal way to get rid of them would be to have a system [in the rest of the hospital] that speaks to ours
- The ICU retains lists of its patients’ medication on a computerised/electronic system
- The rest of the wards in the hospital do not operate the same system
- The available systems do not speak to each other (to put it in somewhat colloquial terms)
- Efforts to address that problem have proved fruitless
- As a result, every time an inpatient moves from ICU to another department in the hospital, an appropriately qualified member of staff has to physically transcribe that patient’s medication list
- With (for instance) 10 patients moving per day, 15-20 medications per patient, and multiple elements for each medication (name; dose; timing; indication; start date; signature etc.), “at a conservative estimate 1,500 to 2,000 elements [are transcribed daily]”
(Coroner’s comment: for obvious reasons this creates enormous potential for human error)
- There are a limited number of people who can prescribe (and are therefore able to perform this task); in critical care they are the same people who are responsible for providing care
- “We really need a second check… funding for more pharmacists… as a Trust we’re falling short of ICU national standards for years in terms of the number of pharmacists per bed and medicines reconciliation”
- “I spoke to the Chief Pharmaceutical Officer – he has submitted 5 proposals in the last 7 years to try to get the deficit funded… [without success]”
In summary, my view is that the circumstances currently in place create a very real (and known) risk that transcription errors will continue to occur . This in turn endangers patients, and creates a risk that people will die in the future as a result of such errors.
It is, sadly, very easy to envisage circumstances in which a patient might not receive essential medication at all, might receive the wrong dose of the medication they need, or might receive the wrong medication altogether, because of a transcription error.
In my opinion there is a risk that future deaths will occur unless action is taken, and in the circumstances it is my statutory duty to report to you.
” 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 Provide routine training for junior and rotational ward pharmacists receiving intensive-care step-down patients.
Verbatim wording from the response “Actions already in place to reduce the risk of transcription errors between ITU and the wards:” Source location Response from University Hospitals Bristol and Weston NHS Foundation 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 Apply a doctor’s second check when prescribers complete ward drug charts.
Verbatim wording from the response “Actions already in place to reduce the risk of transcription errors between ITU and the wards:” Source location Response from University Hospitals Bristol and Weston NHS Foundation 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 Invest in additional adult intensive-care pharmacy staff to provide trained-individual medicines reconciliation five days weekly and weekend safety-net reviews.
Verbatim wording from the response “• You heard in evidence that proposals for additional resource in Pharmacy were presented but, regrettably, there were competing proposals from higher risk areas, which the Trust had to prioritise. I asked the Chief Medical Officer to oversee a review of the funding requests, and entries on the Trust’s risk register, to provide further assurance around this. I confirm that the Trust will invest in additional pharmacy staff for adult ITU to ensure all medicines reconciliation at step down is completed by a suitably trained individual. This will provide a pharmacy medicines reconciliation five days a week. In addition, this investment will provide a safety net review of weekend medicines reconciliation previously undertaken by doctors and advanced nurse practitioners at the weekend at the time of transfer out of ITU.” Source location Response from University Hospitals Bristol and Weston NHS Foundation 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 Implement Careflow Medicines Management across most clinical areas to standardise prescribing and support electronic medicines reconciliation and medication-error controls.
Verbatim wording from the response “For patients in the ward areas of our hospitals, medicines are currently prescribed using paper drug charts. A Trust-wide system for electronic prescribing and medicines administration, Careflow Medicines Management (CMM), for ward based patients is currently being implemented across” Source location Response from University Hospitals Bristol and Weston NHS Foundation 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 Review pharmacy funding requests and relevant Trust risk-register entries to provide assurance about medicines-reconciliation safety.
Verbatim wording from the response “• You heard in evidence that proposals for additional resource in Pharmacy were presented but, regrettably, there were competing proposals from higher risk areas, which the Trust had to prioritise. I asked the Chief Medical Officer to oversee a review of the funding requests, and entries on the Trust’s risk register, to provide further assurance around this. I confirm that the Trust will invest in additional pharmacy staff for adult ITU to ensure all medicines reconciliation at step down is completed by a suitably trained individual. This will provide a pharmacy medicines reconciliation five days a week. In addition, this investment will provide a safety net review of weekend medicines reconciliation previously undertaken by doctors and advanced nurse practitioners at the weekend at the time of transfer out of ITU.” Source location Response from University Hospitals Bristol and Weston NHS Foundation 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 Participate in regional auditing to share learning and identify opportunities to reduce medication errors during intensive-care step-down.
Verbatim wording from the response “Actions already in place to reduce the risk of transcription errors between ITU and the wards:” Source location Response from University Hospitals Bristol and Weston NHS Foundation 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 Provide a designated quiet space for medication transcription.
Verbatim wording from the response “Actions already in place to reduce the risk of transcription errors between ITU and the wards:” Source location Response from University Hospitals Bristol and Weston NHS Foundation 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 Interoperability between prescribing systems cannot be achieved because it requires technical input from competing external providers outside the Trust’s control.
Verbatim wording from the response “In addition, achieving interoperability between the two systems would require extensive technical input from and between the two external competing commercial providers, which would be outside of the Trust’s control.” Source location Response from University Hospitals Bristol and Weston NHS Foundation 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 A unified electronic prescribing system cannot be introduced because ward and intensive-care systems have incompatible specialised requirements.
Verbatim wording from the response “In addressing transcription challenges within the different clinical areas of UHBW, it may seem desirable to have a unified prescribing system. However, it’s important to acknowledge that the Electronic Patient Record system used for ward-based patients would not be suitable for use on ITU given the specialised requirements of the Intensive Care system. This challenge is not unique to UHBW; across the NHS, different clinical areas, including ITU, maternity, and pathology, often operate with disparate systems due to their complex, individual requirements.” Source location Response from University Hospitals Bristol and Weston NHS Foundation Trust
Open published response
Concerns raised 2 Lack of a service level agreement for treatment of patients from Cornwall when the UHP service is unavailable View source Unavailability of a 24/7 thrombectomy service for RCHT patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony James REEDMAN · 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
Anthony James Reedman suffered a basilar artery stroke while at home, but an ambulance delay meant thrombolysis was administered 4.5 hours after the stroke. He died following a further brain haemorrhage after the unsuccessful thrombolysis attempt. The principal concerns were the lack of a 24/7 thrombectomy service for Royal Cornwall Hospital Trust patients and the absence of a service level agreement with the nearest 24/7 service when the local service was unavailable.
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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a service level agreement for treatment of patients from Cornwall when the UHP service is unavailable
Wider context from the report “(2) The nearest 24/7 thrombectomy service is at NHS North Bristol. However, there is no service level agreement between Southmead and RCHT for the treatment of patients from Cornwall when the UHP service is unavailable . This limits the options available to RCHT clinicians in considering treatment for stroke patients.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a 24/7 thrombectomy service for RCHT patients
Wider context from the report “(1) There is no thrombectomy service available 24/7 for RCHT patients. Thrombectomy is considered by clinicians to be a lifesaving procedure. On average, successful outcomes for treatment for a basilar artery stroke are 13% for thrombolysis, and 37% for thrombectomy. Over the last year it is estimated that 75 stroke patients in Cornwall who would otherwise be suitable for thrombectomy procedure did not receive this procedure because it is not available 24/7 in Cornwall, unlike for example those who live in Bristol. A clinical witness described this situation as a postcode lottery.
” 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 Explore with University Hospitals Plymouth and Royal Cornwall Hospital what interim out-of-region thrombectomy referral support North Bristol can offer.
Verbatim wording from the response “On an interim basis, as University Hospitals Plymouth transition to a 24/7 seven days a week thrombectomy service in October 2023, we will explore with them and RCHT what support North Bristol can offer by way of out of region referrals in an attempt to mitigate the risk of patients that are suitable for thrombectomy procedures not receiving this procedure.” Source location Response from North Bristol 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 North Bristol cannot assist further because NHSE commissioning arrangements are outside its control.
Verbatim wording from the response “We apologise we are unable to assist any further than this given the NHSE commissioning arrangements are outside of North Bristol NHS Trust’s control.” Source location Response from North Bristol 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 NHSE Specialised Commissioning decides funding and commissioning for 24/7 thrombectomy services, while UHP is responsible for Cornwall’s tertiary stroke services.
Verbatim wording from the response “expansion. Funding and commissioning of mechanical stroke thrombectomy in England is managed through the local NHS England Specialised Commissioning team.” Source location Response from North Bristol NHS Trust
Open published response
Concerns raised 4 Failure of the patient safety investigation to identify the absence of family notification about the falls risk assessment outcome View source Failure of the patient safety investigation to identify an improperly performed falls risk assessment View source Failure of the patient safety investigation to identify omitted falls risk reassessments View source Failure of the patient safety investigation to identify inaccurate low-risk falls documentation after a fall 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
Mr George Michael ELLIOTT · 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 George Michael Elliott was an 81-year-old inpatient receiving investigation and treatment for an underlying cardiac condition when he fell in hospital on 4 September 2021 and suffered a fatal brain injury, dying on 9 September 2021. The principal concern was that the Patient Safety Investigation overlooked obvious failings in his falls risk assessment and management, including failures to reassess and communicate his risk, thereby missing important patient-safety learning opportunities.
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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the patient safety investigation to identify the absence of family notification about the falls risk assessment outcome
Wider context from the report “My concerns are about the quality (or otherwise) of the Patient Safety Investigation (“PSI”) which took place after Mr ELLIOTT’s death.
In Mr ELLIOTT’s case the investigation (and accompanying report) overlooked obvious failings in his care. As a result important learning opportunities (and therefore important opportunities to improve patient safety in the future) were also missed.
I am concerned that if this investigation (and report) is in any way representative of the quality and rigour of such investigations within the Trust, then the Trust may be missing vital opportunities to learn from its mistakes, and to make its patients (now and in the future) safer as a result of that learning.
To give a little more detail:
• The stated remit of the Patient Safety Investigation was to “review the care episode… [and] to understand the events and identify opportunities to learn and to improve patient safety” (see page 4 of the resulting report)
• Given that this was a case where a patient suffered a fatal injury as the result of an inpatient fall, one of the first and most obvious points to investigate would have been the adequacy (or otherwise) of his falls risk assessment/s, and the extent of the nursing staff’s compliance with any relevant Trust protocols / procedures
• Notwithstanding that background, the PSI report failed to identify the (very obvious) fact that although a falls risk assessment had been performed, it had not been performed properly
• There were also numerous other failings in the approach that had been taken to the assessment of Mr ELLIOTT’s falls risk, and/or the way that risk had been managed while he was an inpatient, but none of these were identified by the PSI / present in the report.
• For example:
- Para.6.13 of the Trust’s then-current Falls Prevention Policy stipulates that Mr ELLIOTT’s family should have been made aware of the outcome of his falls risk assessment. That did not happen , but the fact that it did not happen is not mentioned in the PSI report .
- There is no indication that Mr ELLIOTT’s falls risk was ever re-assessed (after 30 August 2021). According to the Trust’s policy it should have been reassessed after he moved to the Cardiology ward, and again after his fall on 4 September, but no such reassessment took place, and the PSI report makes no mention of these oversights/omissions.
- After Mr ELLIOTT’s fall on 4 September, he continues to be described as at “low risk” of falls in the Daily Intentional Rounding documentation within his medical records. This is an alarming error, but one which has been overlooked entirely by the PSI report.
• I asked Nurse ████████ (one of the PSI-report authors, who gave evidence at the inquest) about the fact that none of these errors had been identified in the report and she had no explanation for why that was the case.
As stated above, if PSI reports overlook clear / obvious failings, then learning opportunities are missed, patient safety is compromised, and there is a risk of future deaths.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the patient safety investigation to identify an improperly performed falls risk assessment
Wider context from the report “My concerns are about the quality (or otherwise) of the Patient Safety Investigation (“PSI”) which took place after Mr ELLIOTT’s death.
In Mr ELLIOTT’s case the investigation (and accompanying report) overlooked obvious failings in his care. As a result important learning opportunities (and therefore important opportunities to improve patient safety in the future) were also missed.
I am concerned that if this investigation (and report) is in any way representative of the quality and rigour of such investigations within the Trust, then the Trust may be missing vital opportunities to learn from its mistakes, and to make its patients (now and in the future) safer as a result of that learning.
To give a little more detail:
• The stated remit of the Patient Safety Investigation was to “review the care episode… [and] to understand the events and identify opportunities to learn and to improve patient safety” (see page 4 of the resulting report)
• Given that this was a case where a patient suffered a fatal injury as the result of an inpatient fall, one of the first and most obvious points to investigate would have been the adequacy (or otherwise) of his falls risk assessment/s, and the extent of the nursing staff’s compliance with any relevant Trust protocols / procedures
• Notwithstanding that background, the PSI report failed to identify the (very obvious) fact that although a falls risk assessment had been performed, it had not been performed properly
• There were also numerous other failings in the approach that had been taken to the assessment of Mr ELLIOTT’s falls risk, and/or the way that risk had been managed while he was an inpatient, but none of these were identified by the PSI / present in the report.
• For example:
- Para.6.13 of the Trust’s then-current Falls Prevention Policy stipulates that Mr ELLIOTT’s family should have been made aware of the outcome of his falls risk assessment. That did not happen, but the fact that it did not happen is not mentioned in the PSI report.
- There is no indication that Mr ELLIOTT’s falls risk was ever re-assessed (after 30 August 2021). According to the Trust’s policy it should have been reassessed after he moved to the Cardiology ward, and again after his fall on 4 September, but no such reassessment took place, and the PSI report makes no mention of these oversights/omissions.
- After Mr ELLIOTT’s fall on 4 September, he continues to be described as at “low risk” of falls in the Daily Intentional Rounding documentation within his medical records. This is an alarming error, but one which has been overlooked entirely by the PSI report.
• I asked Nurse ████████ (one of the PSI-report authors, who gave evidence at the inquest) about the fact that none of these errors had been identified in the report and she had no explanation for why that was the case.
As stated above, if PSI reports overlook clear / obvious failings, then learning opportunities are missed, patient safety is compromised, and there is a risk of future deaths.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the patient safety investigation to identify omitted falls risk reassessments
Wider context from the report “My concerns are about the quality (or otherwise) of the Patient Safety Investigation (“PSI”) which took place after Mr ELLIOTT’s death.
In Mr ELLIOTT’s case the investigation (and accompanying report) overlooked obvious failings in his care. As a result important learning opportunities (and therefore important opportunities to improve patient safety in the future) were also missed.
I am concerned that if this investigation (and report) is in any way representative of the quality and rigour of such investigations within the Trust, then the Trust may be missing vital opportunities to learn from its mistakes, and to make its patients (now and in the future) safer as a result of that learning.
To give a little more detail:
• The stated remit of the Patient Safety Investigation was to “review the care episode… [and] to understand the events and identify opportunities to learn and to improve patient safety” (see page 4 of the resulting report)
• Given that this was a case where a patient suffered a fatal injury as the result of an inpatient fall, one of the first and most obvious points to investigate would have been the adequacy (or otherwise) of his falls risk assessment/s, and the extent of the nursing staff’s compliance with any relevant Trust protocols / procedures
• Notwithstanding that background, the PSI report failed to identify the (very obvious) fact that although a falls risk assessment had been performed, it had not been performed properly
• There were also numerous other failings in the approach that had been taken to the assessment of Mr ELLIOTT’s falls risk, and/or the way that risk had been managed while he was an inpatient, but none of these were identified by the PSI / present in the report.
• For example:
- Para.6.13 of the Trust’s then-current Falls Prevention Policy stipulates that Mr ELLIOTT’s family should have been made aware of the outcome of his falls risk assessment. That did not happen, but the fact that it did not happen is not mentioned in the PSI report.
- There is no indication that Mr ELLIOTT’s falls risk was ever re-assessed (after 30 August 2021) . According to the Trust’s policy it should have been reassessed after he moved to the Cardiology ward, and again after his fall on 4 September, but no such reassessment took place , and the PSI report makes no mention of these oversights/omissions .
- After Mr ELLIOTT’s fall on 4 September, he continues to be described as at “low risk” of falls in the Daily Intentional Rounding documentation within his medical records. This is an alarming error, but one which has been overlooked entirely by the PSI report.
• I asked Nurse ████████ (one of the PSI-report authors, who gave evidence at the inquest) about the fact that none of these errors had been identified in the report and she had no explanation for why that was the case.
As stated above, if PSI reports overlook clear / obvious failings, then learning opportunities are missed, patient safety is compromised, and there is a risk of future deaths.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the patient safety investigation to identify inaccurate low-risk falls documentation after a fall
Wider context from the report “My concerns are about the quality (or otherwise) of the Patient Safety Investigation (“PSI”) which took place after Mr ELLIOTT’s death.
In Mr ELLIOTT’s case the investigation (and accompanying report) overlooked obvious failings in his care. As a result important learning opportunities (and therefore important opportunities to improve patient safety in the future) were also missed.
I am concerned that if this investigation (and report) is in any way representative of the quality and rigour of such investigations within the Trust, then the Trust may be missing vital opportunities to learn from its mistakes, and to make its patients (now and in the future) safer as a result of that learning.
To give a little more detail:
• The stated remit of the Patient Safety Investigation was to “review the care episode… [and] to understand the events and identify opportunities to learn and to improve patient safety” (see page 4 of the resulting report)
• Given that this was a case where a patient suffered a fatal injury as the result of an inpatient fall, one of the first and most obvious points to investigate would have been the adequacy (or otherwise) of his falls risk assessment/s, and the extent of the nursing staff’s compliance with any relevant Trust protocols / procedures
• Notwithstanding that background, the PSI report failed to identify the (very obvious) fact that although a falls risk assessment had been performed, it had not been performed properly
• There were also numerous other failings in the approach that had been taken to the assessment of Mr ELLIOTT’s falls risk, and/or the way that risk had been managed while he was an inpatient, but none of these were identified by the PSI / present in the report.
• For example:
- Para.6.13 of the Trust’s then-current Falls Prevention Policy stipulates that Mr ELLIOTT’s family should have been made aware of the outcome of his falls risk assessment. That did not happen, but the fact that it did not happen is not mentioned in the PSI report.
- There is no indication that Mr ELLIOTT’s falls risk was ever re-assessed (after 30 August 2021). According to the Trust’s policy it should have been reassessed after he moved to the Cardiology ward, and again after his fall on 4 September, but no such reassessment took place, and the PSI report makes no mention of these oversights/omissions.
- After Mr ELLIOTT’s fall on 4 September, he continues to be described as at “low risk” of falls in the Daily Intentional Rounding documentation within his medical records . This is an alarming error, but one which has been overlooked entirely by the PSI report .
• I asked Nurse ████████ (one of the PSI-report authors, who gave evidence at the inquest) about the fact that none of these errors had been identified in the report and she had no explanation for why that was the case.
As stated above, if PSI reports overlook clear / obvious failings, then learning opportunities are missed, patient safety is compromised, and there is a risk of future deaths.
” 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 Report gap-analysis findings and associated system or process improvements to the Patient Safety and Quality Committees.
Verbatim wording from the response “As noted above, we accept that the George Elliott investigation missed some key elements, but do not consider this is reflective of the standard of our Patient Safety Incident Investigations at the Trust. We are presently conducting a gap analysis using the recently published PSIRF national guidance. As part of this, we are re-focusing on how we support expert investigations being conducted by scoping the structure and capacity within our central and divisional teams.” Source location Response from North Bristol 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 Reassess investigation support structures and capacity, including considering new posts dedicated to patient safety investigations.
Verbatim wording from the response “Over the past 4 years, the governance teams within our divisions have undergone significant investment, part of which has been to ensure governance teams are better resourced to support and undertake investigations in relation to patient safety incidents. To continue to strengthen our approach, we are also reassessing our approach to how we support detailed, high-quality investigations, and considering establishing new posts that focus entirely on investigations. This is in line with the recently published national PSIRF guidelines.” Source location Response from North Bristol 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 Review investigation progress, timelines and rigour through the central Patient Safety Team, escalating concerns where necessary.
Verbatim wording from the response “At NBT we have developed and are implementing a process in which the central Patient Safety Team routinely review the progress of investigations. This process focuses on the timelines, but also the rigour being applied to the actual investigation process. Any concerns and feedback will be communicated with the respective Division and, where necessary, escalated to the Chief” Source location Response from North Bristol 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 Conduct a gap analysis against the final national PSIRF guidance to ensure full alignment.
Verbatim wording from the response “In August this year, the final PSIRF documentation was published by NHS England, with all NHS Trusts now transitioning to PSIRF. We in NBT are using the newly published documentation to conduct a gap analysis about the end-state framework documentation. The core reason for the gap analysis is to ensure that, as an early adopter, we are now working in full alignment with the final guidelines that other (non-early adopter) organisations are starting to transition to. This is a process being adopted by all other early adopters.” Source location Response from North Bristol 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 The shortcomings in this investigation are not representative of the Trust’s usual patient safety investigation standards or processes.
Verbatim wording from the response “The Regulation 28 raised concerns about the quality of the investigation report and supporting process following Mr Elliot’s fall in hospital. Furthermore, it raised concerns that if this report were representative of the wider quality of such reports it may indicate that North Bristol NHS Trust may miss opportunities to learn, which may contribute to further deaths.” Source location Response from North Bristol NHS Trust
Open published response
8 Aug 2022 Mr Gerwyn John REES · Prevention of Future Deaths report Avon
View report summary
Concerns raised 5 Failure to identify and disseminate learning from serious incidents View source Failure to allocate the appropriate ECO observation level following falls risk assessment View source Lack of rigour in RCA investigations of ECO-related incidents View source Failure by staff to understand and implement the ECO Policy View source ECO Policy not fit for purpose or safe View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Gerwyn John REES · 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 Gerwyn John REES, who was elderly and frail, was admitted to hospital after experiencing falls and was assessed as requiring low-risk enhanced care observations. He fell twice on 29 November 2020, fracturing his hip, and later died in January 2021 following surgery, as a result of general frailty and the hip injury. The principal concerns were the initial low-risk falls assessment, inadequate steps to prevent the fall, and an apparent lack of learning and investigative rigour following his death.
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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and disseminate learning from serious incidents
Wider context from the report “• I find it very difficult to see how Mr REES could properly have been allocated to level 2 ECO observations (“low risk”) at the time of his initial falls risk assessment on 29 November 2020
• However, notwithstanding that initial concern on my part, I am more concerned by the apparent absence of learning following Mr REES’s death
• The Trust’s Root Cause Analysis (‘RCA’) investigation/report (co-authored by ████████ a Matron / Senior Nurse) does not identify any issue or concern in respect of that initial allocation to ECO level 2
• Further – during the inquest – when I questioned the nurse who had approved the initial “Level 2” allocation on Ward A413 ████████ she initially maintained that ECO Level 2 was appropriate for Mr REES at that time, before later conceding to me that he should have been allocated to Level 3 observations from the outset and that ECO Level 2 was not an appropriate categorisation for him at the time of his initial falls risk assessment
• When I then questioned ████████ (RCA co-author) about this same point, she too initially gave evidence that ECO Level 2 was a reasonable categorisation for Mr REES during the initial falls risk assessment, applying “clinical judgement” (albeit that she later accepted – I think – that it had not been an appropriate categorisation at that time)
• I struggle to see how, as a senior nurse with responsibility for investigating an incident such as this and disseminating learning as a result of it, Nurse ████████ can have suggested to me that ECO 2 was ever appropriate for Mr REES
• The lack of criticism of Mr REES’s initial risk allocation to ECO level 2 in the RCA report, coupled with these aspects of the live evidence of Nurse ████████ and Matron ████████ (see above) suggest to me that there was a lack of investigative rigour in the RCA reporting process, and/or that the ECO Policy was (and is) not properly understood by the staff involved in authoring the RCA, or in implementing the policy
• Whilst it is relatively commonplace to see circumstances in which policies or standard operating procedures have not been properly understood or implemented on a ward, in real time, it is more concerning still to see circumstances such as these; in which even after the Trust’s investigation and learning process have been completed there does not appear to be an appreciation of where mistakes have been made : this of course means that there has been a missed opportunity to learn from the death in question
• For completeness, I do not think that I am wrong in my interpretation of the ECO Policy, but if I am, and if – following that policy properly – a patient with a background such as Mr REES could properly be described as at “low risk” and requiring only the protection that is afforded by ECO level 2, then I would be very concerned that the policy itself was not fit for purpose, or safe.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate the appropriate ECO observation level following falls risk assessment
Wider context from the report “• I find it very difficult to see how Mr REES could properly have been allocated to level 2 ECO observations (“low risk”) at the time of his initial falls risk assessment on 29 November 2020
• However, notwithstanding that initial concern on my part, I am more concerned by the apparent absence of learning following Mr REES’s death
• The Trust’s Root Cause Analysis (‘RCA’) investigation/report (co-authored by ████████ a Matron / Senior Nurse) does not identify any issue or concern in respect of that initial allocation to ECO level 2
• Further – during the inquest – when I questioned the nurse who had approved the initial “Level 2” allocation on Ward A413 ████████ she initially maintained that ECO Level 2 was appropriate for Mr REES at that time, before later conceding to me that he should have been allocated to Level 3 observations from the outset and that ECO Level 2 was not an appropriate categorisation for him at the time of his initial falls risk assessment
• When I then questioned ████████ (RCA co-author) about this same point, she too initially gave evidence that ECO Level 2 was a reasonable categorisation for Mr REES during the initial falls risk assessment, applying “clinical judgement” (albeit that she later accepted – I think – that it had not been an appropriate categorisation at that time)
• I struggle to see how, as a senior nurse with responsibility for investigating an incident such as this and disseminating learning as a result of it, Nurse ████████ can have suggested to me that ECO 2 was ever appropriate for Mr REES
• The lack of criticism of Mr REES’s initial risk allocation to ECO level 2 in the RCA report, coupled with these aspects of the live evidence of Nurse ████████ and Matron ████████ (see above) suggest to me that there was a lack of investigative rigour in the RCA reporting process, and/or that the ECO Policy was (and is) not properly understood by the staff involved in authoring the RCA, or in implementing the policy
• Whilst it is relatively commonplace to see circumstances in which policies or standard operating procedures have not been properly understood or implemented on a ward, in real time, it is more concerning still to see circumstances such as these; in which even after the Trust’s investigation and learning process have been completed there does not appear to be an appreciation of where mistakes have been made: this of course means that there has been a missed opportunity to learn from the death in question
• For completeness, I do not think that I am wrong in my interpretation of the ECO Policy, but if I am, and if – following that policy properly – a patient with a background such as Mr REES could properly be described as at “low risk” and requiring only the protection that is afforded by ECO level 2, then I would be very concerned that the policy itself was not fit for purpose, or safe.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of rigour in RCA investigations of ECO-related incidents
Wider context from the report “• I find it very difficult to see how Mr REES could properly have been allocated to level 2 ECO observations (“low risk”) at the time of his initial falls risk assessment on 29 November 2020
• However, notwithstanding that initial concern on my part, I am more concerned by the apparent absence of learning following Mr REES’s death
• The Trust’s Root Cause Analysis (‘RCA’) investigation/report (co-authored by ████████ a Matron / Senior Nurse) does not identify any issue or concern in respect of that initial allocation to ECO level 2
• Further – during the inquest – when I questioned the nurse who had approved the initial “Level 2” allocation on Ward A413 ████████ she initially maintained that ECO Level 2 was appropriate for Mr REES at that time, before later conceding to me that he should have been allocated to Level 3 observations from the outset and that ECO Level 2 was not an appropriate categorisation for him at the time of his initial falls risk assessment
• When I then questioned ████████ (RCA co-author) about this same point, she too initially gave evidence that ECO Level 2 was a reasonable categorisation for Mr REES during the initial falls risk assessment, applying “clinical judgement” (albeit that she later accepted – I think – that it had not been an appropriate categorisation at that time)
• I struggle to see how, as a senior nurse with responsibility for investigating an incident such as this and disseminating learning as a result of it, Nurse ████████ can have suggested to me that ECO 2 was ever appropriate for Mr REES
• The lack of criticism of Mr REES’s initial risk allocation to ECO level 2 in the RCA report, coupled with these aspects of the live evidence of Nurse ████████ and Matron ████████ (see above) suggest to me that there was a lack of investigative rigour in the RCA reporting process , and/or that the ECO Policy was (and is) not properly understood by the staff involved in authoring the RCA, or in implementing the policy
• Whilst it is relatively commonplace to see circumstances in which policies or standard operating procedures have not been properly understood or implemented on a ward, in real time, it is more concerning still to see circumstances such as these; in which even after the Trust’s investigation and learning process have been completed there does not appear to be an appreciation of where mistakes have been made: this of course means that there has been a missed opportunity to learn from the death in question
• For completeness, I do not think that I am wrong in my interpretation of the ECO Policy, but if I am, and if – following that policy properly – a patient with a background such as Mr REES could properly be described as at “low risk” and requiring only the protection that is afforded by ECO level 2, then I would be very concerned that the policy itself was not fit for purpose, or safe.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by staff to understand and implement the ECO Policy
Wider context from the report “• I find it very difficult to see how Mr REES could properly have been allocated to level 2 ECO observations (“low risk”) at the time of his initial falls risk assessment on 29 November 2020
• However, notwithstanding that initial concern on my part, I am more concerned by the apparent absence of learning following Mr REES’s death
• The Trust’s Root Cause Analysis (‘RCA’) investigation/report (co-authored by ████████ a Matron / Senior Nurse) does not identify any issue or concern in respect of that initial allocation to ECO level 2
• Further – during the inquest – when I questioned the nurse who had approved the initial “Level 2” allocation on Ward A413 ████████ she initially maintained that ECO Level 2 was appropriate for Mr REES at that time, before later conceding to me that he should have been allocated to Level 3 observations from the outset and that ECO Level 2 was not an appropriate categorisation for him at the time of his initial falls risk assessment
• When I then questioned ████████ (RCA co-author) about this same point, she too initially gave evidence that ECO Level 2 was a reasonable categorisation for Mr REES during the initial falls risk assessment, applying “clinical judgement” (albeit that she later accepted – I think – that it had not been an appropriate categorisation at that time)
• I struggle to see how, as a senior nurse with responsibility for investigating an incident such as this and disseminating learning as a result of it, Nurse ████████ can have suggested to me that ECO 2 was ever appropriate for Mr REES
• The lack of criticism of Mr REES’s initial risk allocation to ECO level 2 in the RCA report, coupled with these aspects of the live evidence of Nurse ████████ and Matron ████████ (see above) suggest to me that there was a lack of investigative rigour in the RCA reporting process, and/or that the ECO Policy was (and is) not properly understood by the staff involved in authoring the RCA, or in implementing the policy
• Whilst it is relatively commonplace to see circumstances in which policies or standard operating procedures have not been properly understood or implemented on a ward, in real time , it is more concerning still to see circumstances such as these; in which even after the Trust’s investigation and learning process have been completed there does not appear to be an appreciation of where mistakes have been made: this of course means that there has been a missed opportunity to learn from the death in question
• For completeness, I do not think that I am wrong in my interpretation of the ECO Policy, but if I am, and if – following that policy properly – a patient with a background such as Mr REES could properly be described as at “low risk” and requiring only the protection that is afforded by ECO level 2, then I would be very concerned that the policy itself was not fit for purpose, or safe.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation ECO Policy not fit for purpose or safe
Wider context from the report “• I find it very difficult to see how Mr REES could properly have been allocated to level 2 ECO observations (“low risk”) at the time of his initial falls risk assessment on 29 November 2020
• However, notwithstanding that initial concern on my part, I am more concerned by the apparent absence of learning following Mr REES’s death
• The Trust’s Root Cause Analysis (‘RCA’) investigation/report (co-authored by ████████ a Matron / Senior Nurse) does not identify any issue or concern in respect of that initial allocation to ECO level 2
• Further – during the inquest – when I questioned the nurse who had approved the initial “Level 2” allocation on Ward A413 ████████ she initially maintained that ECO Level 2 was appropriate for Mr REES at that time, before later conceding to me that he should have been allocated to Level 3 observations from the outset and that ECO Level 2 was not an appropriate categorisation for him at the time of his initial falls risk assessment
• When I then questioned ████████ (RCA co-author) about this same point, she too initially gave evidence that ECO Level 2 was a reasonable categorisation for Mr REES during the initial falls risk assessment, applying “clinical judgement” (albeit that she later accepted – I think – that it had not been an appropriate categorisation at that time)
• I struggle to see how, as a senior nurse with responsibility for investigating an incident such as this and disseminating learning as a result of it, Nurse ████████ can have suggested to me that ECO 2 was ever appropriate for Mr REES
• The lack of criticism of Mr REES’s initial risk allocation to ECO level 2 in the RCA report, coupled with these aspects of the live evidence of Nurse ████████ and Matron ████████ (see above) suggest to me that there was a lack of investigative rigour in the RCA reporting process, and/or that the ECO Policy was (and is) not properly understood by the staff involved in authoring the RCA, or in implementing the policy
• Whilst it is relatively commonplace to see circumstances in which policies or standard operating procedures have not been properly understood or implemented on a ward, in real time, it is more concerning still to see circumstances such as these; in which even after the Trust’s investigation and learning process have been completed there does not appear to be an appreciation of where mistakes have been made: this of course means that there has been a missed opportunity to learn from the death in question
• For completeness, I do not think that I am wrong in my interpretation of the ECO Policy, but if I am, and if – following that policy properly – a patient with a background such as Mr REES could properly be described as at “low risk” and requiring only the protection that is afforded by ECO level 2, then I would be very concerned that the policy itself was not fit for purpose, or safe .
” 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 Strengthen the Enhanced Care Observation policy with North Bristol NHS Trust partners.
Verbatim wording from the response “In addition, to provide equitable and consistent care for all our patients, we will look at strengthening the ECO policy along with our partners in North Bristol NHS Trust.” Source location Response from University Hospital Bristol and Weston
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 alternative methods for reviewing and learning from patient-safety events that do not require full investigation.
Verbatim wording from the response “• There will be alternative methods for reviewing and learning from patient safety events that do not meet the criteria for a full patient safety incident investigation.” Source location Response from University Hospital Bristol and Weston
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 affected staff groups with support, education, training, ward signs, meaningful-activities resources and task kits after policy approval.
Verbatim wording from the response “Once the updated policy has been approved, key staff groups affected by the ECO policy will be provided support, education, and training in applying the policy in practice. This will include display signs in ward areas, a meaningful activities list and task kits, and additional training to the ECO team from the dementia, delirium and falls team.” Source location Response from University Hospital Bristol and Weston
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 level 3 patient-safety investigation training for seven relevant staff members.
Verbatim wording from the response “• Seven members of staff working in patient safety roles in UHBW have undertaken the new level 3 investigation training made available by the Healthcare Safety Investigation Branch (HSIB) in early 2022 (or possess a recognised Masters level” Source location Response from University Hospital Bristol and Weston
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 Implement the agreed and funded patient-safety investigation model, including a central team of expert investigators and a human-factors specialist.
Verbatim wording from the response “Unfortunately, pace was impeded by the Covid-19 pandemic and the need to prioritise clinical service provision however in the past 12 months practical preparations have taken off to enable transfer to the new framework by June 2023. A number of changes have already been made which are relevant to this response with more currently underway and planned which are summarised below.” Source location Response from University Hospital Bristol and Weston
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 Enhance governance arrangements for learning and improvement from patient-safety incidents.
Verbatim wording from the response “• Governance arrangements for learning and improvement from patient safety incidents will continue and be enhanced.” Source location Response from University Hospital Bristol and Weston
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 Implement the revised Enhanced Care Observation and Meaningful Activities Policy with non-numbered observation categories and holistic patient-needs guidance.
Verbatim wording from the response “As a direct result of this case, we have reconsidered our Enhanced Care Observation (ECO) and Meaningful Activities Policy and are in the process of implementing a revised policy to take on board our learning from this case. It is expected that this updated policy will be in place by November 2022. The updated policy removes the levels of 1, 2, 3, and 4 for ECO, which sometimes causes confusion amongst practitioners and replaces the levels for all inpatients requiring observations with:” Source location Response from University Hospital Bristol and Weston
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 The patient’s admission presentation did not trigger higher observation because he was calm, oriented, engaged, and able to follow instructions.
Verbatim wording from the response “We have reflected on the Root Cause Analysis carried out in this case with particular regard to the concerns you have raised. When assessing the falls risk for new patients admitted to hospital, we consider many aspects including their past medical history, reason for admission, and the presentation of the patient at that time. In Mr Rees’ case he was assessed on admission and assigned ECO level 2. At the time of presentation Mr Rees was found to be alert, orientated, not agitated, and calm. Mr Rees was able to hold a coherent conversation and was able to understand instructions to sit and wait for help to assist him to mobilise. Mr Rees was not putting himself at risk e.g., he was not attempting to mobilise on his own. We recognised that Mr Rees was an elderly gentleman with a history of previous falls and underlying mental health and medical health issues.” Source location Response from University Hospital Bristol and Weston
Open published response
Concerns raised 4 Failure to be open about investigation findings View source Failure of the Plastic Surgery department to properly investigate serious untoward incidents View source Failure of the Plastic Surgery department to acknowledge, respond to, investigate, disclose, or admit mistakes View source Failure of Plastic Surgery consultants to cooperate with or progress investigations 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
Lesley Julie BRASS · 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
Lesley Julie BRASS fell at home, sustained a head injury, and was admitted to hospital after her wound became infected. While an inpatient, she developed severe hyperkalaemia but did not receive the required emergency treatment within the specified timeframe, and she suffered a fatal cardiac arrest. The report raises concerns about failures to recognise, escalate and treat the condition, and about the Plastic Surgery department’s subsequent investigation, openness and willingness to acknowledge mistakes.
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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to be open about investigation findings
Wider context from the report “During the course of the pre-inquest investigation, and at the inquest itself, evidence came to light which led me to conclude that the Trust in general, and the Plastic Surgery department in particular, was/were reluctant to investigate Mrs Brass’s death properly, and to be open about their findings .
I am particularly concerned that a number of the consultants from the Plastic Surgery department failed to co-operate with and/or progress the 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Plastic Surgery department to properly investigate serious untoward incidents
Wider context from the report “During the course of the pre-inquest investigation, and at the inquest itself, evidence came to light which led me to conclude that the Trust in general, and the Plastic Surgery department in particular, was/were reluctant to investigate Mrs Brass’s death properly , and to be open about their findings.
I am particularly concerned that a number of the consultants from the Plastic Surgery department failed to co-operate with and/or progress the 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Plastic Surgery department to acknowledge, respond to, investigate, disclose, or admit mistakes
Wider context from the report “As is, I hope, clear from the outline that I have presented above, this case has left me worried about the investigation of serious untoward incidents generally, and extremely concerned at the attitude and behaviour of the Plastic Surgery department.
The evidence as a whole demonstrates to me a department that has – at Consultant level – been serially unwilling to acknowledge, respond to, investigate, be open about, or admit to its mistakes . The attitude and approach of the Plastic Surgery department, as exemplified in part by failings in the approach of others involved in the initial DATIX investigation, creates a risk of further deaths in the future unless action is taken: a department which refuses to investigate or accept its mistakes cannot learn from them.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Plastic Surgery consultants to cooperate with or progress investigations
Wider context from the report “During the course of the pre-inquest investigation, and at the inquest itself, evidence came to light which led me to conclude that the Trust in general, and the Plastic Surgery department in particular, was/were reluctant to investigate Mrs Brass’s death properly, and to be open about their findings.
I am particularly concerned that a number of the consultants from the Plastic Surgery department failed to co-operate with and/or progress the investigation .
” Open source report
16 Dec 2019 Alice Marie Sloman · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to refer patients with multiple developmental, sensory and physical conditions for investigation of an underlying disorder by a clinical geneticist View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alice Marie Sloman · 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
Alice Marie Sloman died after a routine general anaesthetic for an MRI scan precipitated cardiac decompensation associated with an undiagnosed cardiomyopathy. The principal concern was that, despite multiple conditions and her parents’ requests, she was not referred for investigation of an underlying disorder, including a clinical geneticist’s opinion, and her serious cardiomyopathy therefore went undiagnosed.
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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients with multiple developmental, sensory and physical conditions for investigation of an underlying disorder by a clinical geneticist
Wider context from the report “The evidence demonstrated that Alice was under the care of a consultant community paediatrician, a consultant general paediatrician with an interest in endocrinology and a consultant paediatric endocrinologist presenting with a number of conditions (Growth hormone deficiency, Autistic Spectrum disorder, developmental delay, visual impairment, mobility impairment, poor coordination/dyspraxia and hypermobility) over a 4 year period but was not referred for investigation of an underlying disorder, specifically a clinical geneticist’s opinion , despite her parents requesting this on at least 2 separate occasions which are documented and despite such facility being readily available in Exeter . The evidence demonstrated that as a result her underlying condition, and specifically a serious cardiomyopathy, went undiagnosed resulting in her dying unexpectedly and prematurely as a result of a routine general anaesthetic.
” 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 Develop a patient information leaflet explaining lead clinician responsibility for patients attending regional clinics.
Verbatim wording from the response “Extensive discussions have taken place between the two Trusts, at specialty and senior level, to finalise the Principles of Shared Care for Endocrine referred to at the Inquest. In addition, we have developed a patient information leaflet to ensure that patients and their families understand which lead clinician has overall responsibility for their care when they are treated at a regional clinic. This action is key to addressing your concern that Alice was under the care of a number of clinicians, yet a referral to a geneticist was not made.” Source location 2019-0442-Response-from-Bristol-NHS-Foundation-Redacted-2
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 Finalise and adopt Principles of Shared Care for Endocrine and a corresponding patient information leaflet by the end of March 2020.
Verbatim wording from the response “Extensive discussions have taken place between the two Trusts, at specialty and senior level, to finalise the Principles of Shared Care for Endocrine referred to at the Inquest. In addition, we have developed a patient information leaflet to ensure that patients and their families understand which lead clinician has overall responsibility for their care when they are treated at a regional clinic. This action is key to addressing your concern that Alice was under the care of a number of clinicians, yet a referral to a geneticist was not made.” Source location 2019-0442-Response-from-Bristol-NHS-Foundation-Redacted-2
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 Formalise regional-clinic agreements through Service Level Agreements defining accountability and responsibility.
Verbatim wording from the response “In respect of our wider obligations, the Divisional Director for the Women’s and Children’s Division at UHB met with our Medical Director for Specialist Commissioning (South West) of NHS England on 10 December 2019 to discuss the regional clinics hosted by UHB. It has been agreed that Service Level Agreements will formalise the agreements in place with clear lines of accountability and responsibility. As part of the ‘hub and spoke model’ detailed within the Principles, we support a number of specialties in the region. The review of the governance and operational management of the regional clinics is underway and it is envisaged that this will be completed within the next 12 months.” Source location 2019-0442-Response-from-Bristol-NHS-Foundation-Redacted-2
Open published response
Concerns raised 1 Failure to ensure that outpatients are not lost to follow-up care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Robert Andrew Power · 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
Robert Andrew Power, a 49-year-old man living in a neurological care home, had a chronic brain condition and experienced recurrent aspiration pneumonia and seizure activity. He died on 17 May 2017 after being discharged for palliative care following admission with aspiration pneumonia. The principal concern was that, while treated by the trust, he was lost to outpatient follow-up between 2007 and 2015, creating a risk that future deaths may occur unless patients are not lost to follow-up care.
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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that outpatients are not lost to follow-up care
Wider context from the report “Robert whilst being treated as a patient by the trust was essentially lost to follow up between 2007 – 2015. No explanation was given as to why this happened.
For the reasons given in my summary of evidence I determined that there was no evidence that this area of concern had any direct causative impact on Robert’s death. However in my opinion there is a risk that future deaths may occur unless action is taken to ensure that outpatients are not lost to follow up care . It is acknowledged that significant steps have already been made.
” 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 Introduce processes to arrange patient follow-up appointments.
Verbatim wording from the response “The information provided confirms the Trust is now working under different systems than in 2008 and that processes have been introduced to arrange follow-up appointments and monitor and manage a patient on an allocated pathway.” Source location 2018-0221-Response-by-North-Bristol-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 processes to monitor and manage patients on allocated pathways.
Verbatim wording from the response “The information provided confirms the Trust is now working under different systems than in 2008 and that processes have been introduced to arrange follow-up appointments and monitor and manage a patient on an allocated pathway.” Source location 2018-0221-Response-by-North-Bristol-NHS-Trust
Open published response
8 Jun 2018 Graham William FOX · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to ensure consistent understanding that NEWS-triggered clinical responses are mandatory View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Graham William FOX · 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
Graham William FOX was admitted to hospital after a fall in the community in which he broke both ankles. His condition deteriorated, but NEWS assessment and referral were not correctly implemented overnight, and he was not seen by a doctor as he should have been; he was admitted to the Critical Care Unit the following morning and subsequently died. Concerns included misunderstanding among some nursing staff about whether NEWS responses were mandatory and the use of “re-triggering” under NEWS without expert evidence about its clinical appropriateness.
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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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure consistent understanding that NEWS-triggered clinical responses are mandatory
Wider context from the report “(1) The standard NEWS documentation contains a list of scores on the left, and corresponding clinical responses in a column on the right. My understanding of the system was that when the relevant score was reached, the corresponding clinical response was mandatory. The impression I gained from listening to the majority of the nursing staff was that there was an element of discretion / clinical judgment to be applied in determining whether the clinical responses that were ‘required’ when the relevant score was reached were actually necessary. The more senior nursing staff were clear that the relevant responses were mandatory, but that was not the impression given by the more junior staff . This evidence (which gave the impression that staff discretion could be applied to the clinical responses) was given after the staff had, apparently, been given additional NEWS training following Mr Fox’s 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 Implement CareFlow to automate escalation notifications to the relevant doctor or senior nurse under the escalation protocol.
Verbatim wording from the response “At present, such escalation is completed by telephone or in person, but we will shortly be implementing a further clinical communications system (“CareFlow”) whereby the escalation will be automated to the relevant doctor or senior nurse in accordance with the escalation protocol. The CareFlow system is currently being used in a few areas for some elements of clinical communication.” Source location 2018-0192-Response-by-University-Hospitals-Bristol-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 Deliver training and education on revised escalation alongside implementation of the electronic observations system.
Verbatim wording from the response “We have been supporting the implementation of the e-observations with a further programme of training and education on revised escalation and will continue to do so as we switch to the new national early warning score (NEWS2) planned for October 2018.” Source location 2018-0192-Response-by-University-Hospitals-Bristol-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 Operate electronic observations that calculate NEWS, prompt timely repeat observations, and trigger escalation under the Trust protocol.
Verbatim wording from the response “Since this incident the Trust has implemented an e-observations system in our adult in-patient wards whereby the patient's physiological measurements are entered electronically into a hand held device, which automatically calculates the national early warning score (NEWS) and prompts the staff member to repeat the observations in the required timeframe and to escalate to the relevant clinician in accordance with the Trust's escalation protocol.” Source location 2018-0192-Response-by-University-Hospitals-Bristol-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 Documented revised escalation plans are considered appropriate after clinical review where defined conditions are met, rather than requiring automatic re-triggering.
Verbatim wording from the response “With regards to the practice of “re-triggering”, this perhaps should be more accurately referred to as “revised escalation” and we have been promoting this terminology within the Trust since we commenced implementing the e-observations system towards the end of 2017. Some patients do have elevated early warning scores due to a long term condition which is “normal for them”; in these situations it can be appropriate for a doctor to document a clear revised escalation plan setting out the circumstances an escalation should be enacted.” Source location 2018-0192-Response-by-University-Hospitals-Bristol-NHS-Trust
Open published response
26 Apr 2018 Yazin ELHAJE · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to provide safety-netting advice addressing meningitis when it is part of the differential diagnosis 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
Yazin ELHAJE · 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
Yazin Elhaje became ill with suspected meningitis, was initially discharged with a diagnosis of sinusitis, deteriorated, and died from bacterial meningitis on 8 October 2017 despite treatment. The principal concern was that discharge safety-netting advice to his parents addressed headaches rather than the differential diagnosis of meningitis.
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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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide safety-netting advice addressing meningitis when it is part of the differential diagnosis
Wider context from the report “I heard during the inquest that the safety-netting advice on discharge given to Yazin’s parents was in relation to his headaches and not in relation to the differential diagnosis of meningitis .
I would ask that consideration is given to the safety-netting advice provided to parents in cases where meningitis has been considered as part of the differential diagnosis as in this case.
” 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 a safety-netting process and leaflet for families of children presenting with sinusitis, including information about rare complications such as meningitis.
Verbatim wording from the response “Following this incident the Emergency Department governance lead has led the development of an information leaflet to be given to families whose children present with sinusitis that includes information about rare potential complications such as meningitis.” Source location Response from University Hospitals Bristol NHS Trust
Open published response
28 Mar 2018 John Frederick Wherlock · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to stagger staff breaks to maintain adequate ward cover 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
John Frederick Wherlock · 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
John Frederick Wherlock was an inpatient at Bristol Royal Infirmary who was elderly, confused and at high risk of falls. He was left unsupervised while ward staffing was reduced because two staff were taking breaks at the same time, fell and fractured his other hip, and subsequently died. The principal concerns were inadequate cover during simultaneous staff breaks and the continuation of that practice despite it having been criticised in a serious untoward incident report.
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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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to stagger staff breaks to maintain adequate ward cover
Wider context from the report “(1) I was told in evidence that at the time of the accident the ward was being covered by two nurses and two nursing assistants (ie, by 4 staff), but that two of those staff had taken their 1-hour break at the same time; effectively leaving the ward with very little cover . The fall had then occurred when a nursing assistant left the deceased’s bay to help another member of staff to change a bed (leaving him entirely unsupervised).
(2) While I would be concerned in any event that staff had taken their breaks at the same time – given the effect that that would inevitably have on the remaining nurses’ ability to cope with the patients on the ward – I was even more concerned when the nursing assistant who gave live evidence at the inquest told me that this was a practice which was still taking place ; despite it having been highlighted and criticised in the serious untoward incident report;
” Open source report
Concerns raised 1 Lack of handover information about babies covered by nurses during breaks 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
Rayan AHMED · 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
Rayan Ahmed, a premature baby cared for in a special care unit, collapsed on 6 July 2016 after his deteriorating condition went unrecognised for 1 hour and 5 minutes. He suffered an unsurvivable catastrophic brain injury and died on 9 July 2016. The principal concern was that nurses covering breaks cared for babies they knew nothing about, with inadequate handover arrangements identified as an issue.
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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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of handover information about babies covered by nurses during breaks
Wider context from the report “I was concerned to note during the evidence that nurses in the special care unit are left caring for babies that they know nothing about when covering a break . I would therefore ask that this matter is reviewed and that there is consideration given to the handover at the start of the shifts to include not only the babies that the nurse is directly caring for but also to include the others that the nurse may have to take responsibility for during her shift when her colleague is say taking a break, alternatively that there is a handover at the break.
” Open source report
18 Apr 2017 David Lee BIRTWISTLE · Prevention of Future Deaths report Avon
View report summary
Concerns raised 4 Failure to provide NHS 111 information to ED departments in a user-friendly format View source Failure of front-door ED streaming to include basic physiological measurements View source Delays in NHS 111 sharing information with emergency departments View source Lack of integrated front-door ED streaming by primary and secondary care clinicians 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
David Lee BIRTWISTLE · 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
David Lee Birtwistle died from a pulmonary embolism after being diverted from an accident and emergency assessment two days before his death, meaning further tests were not carried out. Concerns included the absence of NHS 111 referral information for the front door or emergency department and the need for NHS 111 to share information with emergency departments in a user-friendly format.
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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide NHS 111 information to ED departments in a user-friendly format
Wider context from the report “2. NHS 111 should share information with ED departments immediately. This needs to be in a user friendly format.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of front-door ED streaming to include basic physiological measurements
Wider context from the report “1. Streaming of the front door of ED should be an integrated function run by both primary and secondary care clinicians. This should include at least a basic set of physiological measurements.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in NHS 111 sharing information with emergency departments
Wider context from the report “2. NHS 111 should share information with ED departments immediately. This needs to be in a user friendly format.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of integrated front-door ED streaming by primary and secondary care clinicians
Wider context from the report “1. Streaming of the front door of ED should be an integrated function run by both primary and secondary care clinicians. This should include at least a basic set of physiological measurements.
” Open source report
Concerns raised 4 Lack of a standardised referral process for the ‘hot foot’ clinic View source Insufficient resources for demand from new and follow-up patients at the ‘hot foot’ clinic View source Delays in prioritising urgent referrals to the ‘hot foot’ clinic View source Lack of guidance for referrers on clinic referral and alternative assessment and treatment options 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
Ms. Marilyn Anson · 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
Ms. Marilyn Anson had diabetes and end-stage renal failure requiring dialysis, and developed a severe left-foot pressure ulcer. An urgent referral to the ‘hot foot’ clinic was made on 26 February 2015, but the earliest appointment offered was 17 March; the ulcer deteriorated, requiring hospital admission, antibiotics and amputation surgery, and she died after further surgery on 22 March 2015. The concerns included the prioritisation and resourcing of the clinic, coordination between relevant organisations, and guidance and standardisation of referrals.
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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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a standardised referral process for the ‘hot foot’ clinic
Wider context from the report “(1) An urgent referral was made by the community nurses to the ‘hot foot’ clinic on 26th February 2015 and no appointment could be offered until 17th March 2015.
(2) Before this appointment date the deceased’s ulcer had deteriorated and she had been admitted to hospital where she later died.
(3) There should be a review of the means by which patients who are referred to this clinic are prioritised.
(4) There should be a review of the resources allocated to this clinic in the light of demand from new and follow-up patients.
(5) The NSCP should collaborate with Weston Area Health Trust and other relevant stakeholders to ensure current and future resources are used efficiently and effectively.
(6) There should be provided guidance to those who refer patients to this clinic with regard to referring patients to this clinic and other options for assessment and treatment as well as a standardised means of referral so that all patients are prioritised according to clinical need .
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources for demand from new and follow-up patients at the ‘hot foot’ clinic
Wider context from the report “(1) An urgent referral was made by the community nurses to the ‘hot foot’ clinic on 26th February 2015 and no appointment could be offered until 17th March 2015.
(2) Before this appointment date the deceased’s ulcer had deteriorated and she had been admitted to hospital where she later died.
(3) There should be a review of the means by which patients who are referred to this clinic are prioritised.
(4) There should be a review of the resources allocated to this clinic in the light of demand from new and follow-up patients .
(5) The NSCP should collaborate with Weston Area Health Trust and other relevant stakeholders to ensure current and future resources are used efficiently and effectively .
(6) There should be provided guidance to those who refer patients to this clinic with regard to referring patients to this clinic and other options for assessment and treatment as well as a standardised means of referral so that all patients are prioritised according to clinical need.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in prioritising urgent referrals to the ‘hot foot’ clinic
Wider context from the report “(1) An urgent referral was made by the community nurses to the ‘hot foot’ clinic on 26th February 2015 and no appointment could be offered until 17th March 2015 .
(2) Before this appointment date the deceased’s ulcer had deteriorated and she had been admitted to hospital where she later died.
(3) There should be a review of the means by which patients who are referred to this clinic are prioritised .
(4) There should be a review of the resources allocated to this clinic in the light of demand from new and follow-up patients.
(5) The NSCP should collaborate with Weston Area Health Trust and other relevant stakeholders to ensure current and future resources are used efficiently and effectively.
(6) There should be provided guidance to those who refer patients to this clinic with regard to referring patients to this clinic and other options for assessment and treatment as well as a standardised means of referral so that all patients are prioritised according to clinical need .
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for referrers on clinic referral and alternative assessment and treatment options
Wider context from the report “(1) An urgent referral was made by the community nurses to the ‘hot foot’ clinic on 26th February 2015 and no appointment could be offered until 17th March 2015.
(2) Before this appointment date the deceased’s ulcer had deteriorated and she had been admitted to hospital where she later died.
(3) There should be a review of the means by which patients who are referred to this clinic are prioritised.
(4) There should be a review of the resources allocated to this clinic in the light of demand from new and follow-up patients.
(5) The NSCP should collaborate with Weston Area Health Trust and other relevant stakeholders to ensure current and future resources are used efficiently and effectively.
(6) There should be provided guidance to those who refer patients to this clinic with regard to referring patients to this clinic and other options for assessment and treatment as well as a standardised means of referral so that all patients are prioritised according to clinical need.
” Open source report
Concerns raised 1 Delays in providing CBT to children assessed as needing it View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sian Leigh ARMSTRONG · 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
Sian Leigh ARMSTRONG had a history of depression and had previously attempted suicide by overdose. She was assessed as needing CBT after this attempt, but had not received it by her death in June 2014. The principal concern was the delay in providing CBT, with a request for reassurance that it would be made available to children requiring it in a timely manner.
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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in providing CBT to children assessed as needing it
Wider context from the report “1. There was a delay in Sian receiving CBT which she was assessed as requiring.
” 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 Involve Off the Record staff in CAMHS intake meetings and finalise governance arrangements for cross-organisational working.
Verbatim wording from the response “• Bristol and South Gloucestershire Clinical Commissioning Groups (CCG) directly commission Tier 2 services from Off the Record. We are working with our two CCG’s, to involve Off the Record in our CAMHS intake meetings” Source location 2015-0019-North-Bristol-NHS-Trust
Open published response
Concerns raised 3 Failure to raise concerns about inadequate neck immobilisation View source Failure to properly immobilise the neck of patients with cervical spine fractures View source Unavailability of suitable cervical collars 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
Mr Robert Anthony Perkins · 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 Robert Anthony Perkins, who had terminal cancer, was admitted after a fall and was found to have a cervical spine fracture. Despite neurosurgical instructions, a cervical collar was not fitted while he was on the ward, and a suitable collar was difficult to obtain before his transfer to a hospice, where he died. The report raised concerns that inadequate immobilisation placed him at risk of serious or fatal injury and that suitable collars were not readily 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to raise concerns about inadequate neck immobilisation
Wider context from the report “(1) Notwithstanding the instructions of the neurosurgeons no effort was made to obtain and fit a cervical collar throughout the time he was on the ward. It was fortuitous that the patient did not suffer neurological injury. However, he was at risk of serious injury and death as a consequence of the failure to immobilise the neck.
(3) Other than the Specialist Registrar no concerns were raised by medical staff that the patient's neck was not properly immobilised both on the ward and on discharge .
(4) The hospital is a regional centre for neurosciences and neurosurgery yet the prescribed cervical collar was not available and the Registrar had difficulty locating a suitable collar.
(5) The failure to properly immobilise the neck of patients with fractures of the cervical spine, whether on the instructions of neurosurgeons or otherwise, could place those patients at risk of significant and disabling injury and 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly immobilise the neck of patients with cervical spine fractures
Wider context from the report “(1) Notwithstanding the instructions of the neurosurgeons no effort was made to obtain and fit a cervical collar throughout the time he was on the ward . It was fortuitous that the patient did not suffer neurological injury. However, he was at risk of serious injury and death as a consequence of the failure to immobilise the neck .
(3) Other than the Specialist Registrar no concerns were raised by medical staff that the patient's neck was not properly immobilised both on the ward and on discharge.
(4) The hospital is a regional centre for neurosciences and neurosurgery yet the prescribed cervical collar was not available and the Registrar had difficulty locating a suitable collar.
(5) The failure to properly immobilise the neck of patients with fractures of the cervical spine , whether on the instructions of neurosurgeons or otherwise, could place those patients at risk of significant and disabling injury and 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of suitable cervical collars
Wider context from the report “(1) Notwithstanding the instructions of the neurosurgeons no effort was made to obtain and fit a cervical collar throughout the time he was on the ward. It was fortuitous that the patient did not suffer neurological injury. However, he was at risk of serious injury and death as a consequence of the failure to immobilise the neck.
(3) Other than the Specialist Registrar no concerns were raised by medical staff that the patient's neck was not properly immobilised both on the ward and on discharge.
(4) The hospital is a regional centre for neurosciences and neurosurgery yet the prescribed cervical collar was not available and the Registrar had difficulty locating a suitable collar .
(5) The failure to properly immobilise the neck of patients with fractures of the cervical spine, whether on the instructions of neurosurgeons or otherwise, could place those patients at risk of significant and disabling injury and 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 Re-publicise the hard-collar safety alert across the Medical Directorate and Trustwide clinical directorates.
Verbatim wording from the response “Following the inquest the Clinical Director (CD) of the Medicine Directorate discussed this case with his neurosurgical colleagues, in particular awareness and understanding regarding the use of collars. I enclose a hard collar safety alert dated October 2011. The CD will re-publicise this issue by sending this alert out again to the Medical Directorate, and to other CDs to ensure that there is Trustwide distribution in the few days also and include it in future medical induction of new junior medical staff (the next one will be in August 2014).” Source location 2014-0195-Response-by-North-Bristol-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 Include the hard-collar safety alert in future medical induction for new junior medical staff.
Verbatim wording from the response “Following the inquest the Clinical Director (CD) of the Medicine Directorate discussed this case with his neurosurgical colleagues, in particular awareness and understanding regarding the use of collars. I enclose a hard collar safety alert dated October 2011. The CD will re-publicise this issue by sending this alert out again to the Medical Directorate, and to other CDs to ensure that there is Trustwide distribution in the few days also and include it in future medical induction of new junior medical staff (the next one will be in August 2014).” Source location 2014-0195-Response-by-North-Bristol-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 Establish a central Emergency Zone storage location for rigid cervical collars.
Verbatim wording from the response “The accessibility of rigid collars for the purposes of cervical immobilisation is something that is also being addressed now since the move into the new Brunel building. A place for central storage of these devices is being looked for within the Emergency Zone. By creating a single area for the location of these devices it should make it easier to know where to find a collar when the device is needed. It is anticipated that this action should be completed by the end of June 2014.” Source location 2014-0195-Response-by-North-Bristol-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 Report the Regulation 28 findings to the Medical Directorate’s clinical governance agenda.
Verbatim wording from the response “The regulation 28 report will also be reported on in part B of the Medical Directorate’s clinical governance agenda on 26 June 2014. From here it will be decided on whether any further action needs to be taken. Following this, it is likely that a further notification will be made to the directorate’s medical teams to ensure that they are all familiar with the need to review plans for cervical immobilisation when a patient is admitted with a cervical neck injury and the location of the rigid collar devices.” Source location 2014-0195-Response-by-North-Bristol-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 Clarify handover communication when a rigid collar is not applied, including reasons, interim neck-care requirements and reattempt timing.
Verbatim wording from the response “It is clear that communication of these issues is vital to prevent a recurrence of a similar case. It is agreed that communication should include, where there is a failure to apply a rigid collar in the ED, the reasons why the collar was not applied and the nursing aspects for the neck in the interim and when a reattempt at applying the collar should occur.” Source location 2014-0195-Response-by-North-Bristol-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 Further collar application was not pursued because the patient could not tolerate collars and persistence or sedation risked causing greater harm and distress.
Verbatim wording from the response “From investigations it appears that whilst in the Emergency Department (ED) Mr Perkins was too agitated to wear a rigid collar and persistence in trying to put a collar on or even just wearing a collar would likely to have caused more harm and distress to him. Also the ED consultant felt it inappropriate to sedate Mr Perkins for the purposes of applying the collar, again due to the risks of harm from sedation.” Source location 2014-0195-Response-by-North-Bristol-NHS-Trust
Open published response
Concerns raised 1 Delays in reception-area management before triage for people needing immediate care and treatment 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
Chloe Grace FLAVELL · 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
Chloe Grace Flavell became unwell and was taken to Weston General Hospital on 3 April 2013, where she died at 14:30. She was aged 3 days, and the inquest recorded congenital heart disease as the cause of death, with death from natural causes contributed to by neglect. The principal concern was that management of the reception area before triage could cause significant delays in providing immediate care and treatment, particularly for children.
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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reception-area management before triage for people needing immediate care and treatment
Wider context from the report “It became apparent during the evidence that the management of the reception area, i.e. the stage before triage, could add significant delay when assessing someone who was in need of immediate care and treatment especially a child .
I therefore indicated at the conclusion of the inquest that I would write to the Trust about the management of the reception area for them to consider whether there ought to be a better system in place to ensure that those needing immediate care and treatment, especially children, are managed in a more appropriate and efficient way to minimise delay and ensure that immediate care and treatment is given
” 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 Establish new pathways for managing paediatric patients entering the Emergency Department.
Verbatim wording from the response “For your further assurance I enclose a copy of a summary paper of actions taken around paediatrics and presented to the Board on 7th January. Within this paper you will see the new pathways along which paediatric patients can be managed. I would draw your particular attention to the role of the Clinical Navigator. This individual, stationed opposite the reception area in the Emergency Department, has the responsibility of scanning patients as they come into the Department and actively seeking out children who will then be fast tracked along whatever pathway seems most appropriate.” Source location Flavell-2014-0003R_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 Establish a Clinical Navigator role to identify children at Emergency Department reception and fast-track them to appropriate pathways.
Verbatim wording from the response “For your further assurance I enclose a copy of a summary paper of actions taken around paediatrics and presented to the Board on 7th January. Within this paper you will see the new pathways along which paediatric patients can be managed. I would draw your particular attention to the role of the Clinical Navigator. This individual, stationed opposite the reception area in the Emergency Department, has the responsibility of scanning patients as they come into the Department and actively seeking out children who will then be fast tracked along whatever pathway seems most appropriate.” Source location Flavell-2014-0003R_Redacted
Open published response
27 Sep 2013 Jared William McDowall · Prevention of Future Deaths report Avon
View report summary
Concerns raised 4 Lack of competency-assessed education on recognising an unwell baby for doctors and midwives View source Inadequate risk-based criteria and guidance for admission to the transitional area View source Lack of competency-assessed education on hypoglycaemia for doctors and midwives View source Failure to establish effective joint working between doctors and midwives 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
Jared William McDowall · 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
Jared William McDowall was born on 15 January 2012 and died unexpectedly at the hospital on 17 January 2012, aged 48 hours. The inquest concluded that he died from natural causes and had medical conditions that had not been diagnosed. Concerns included the weight thresholds used to determine monitoring, the need for guidance based on gestation and sex, improved presentation of risk information, joint working, and education on hypoglycaemia and recognising an unwell baby.
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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of competency-assessed education on recognising an unwell baby for doctors and midwives
Wider context from the report “During the inquest I heard evidence of a cut off weight for babies to go into a transitional area where they will receive more careful monitoring. Currently the guideline is babies weighing over 2.5kg do not need to go into this unit. ████████ a Consultant Neonatologist from the hospital gave evidence about this and indicated that there should be different weights for gestation and different guides for boys and girls. He also said that the presentation of the evidence would be better if it was graphically done and that by referring to a graph it would give a better understanding of a baby being at risk to the staff.
In addition ████████ said that there was a need to synthesize joint working with doctors and midwives. That there should be educational packages for hypoglycaemia and for recognising an unwell baby for both doctors and midwives with a measurement of competency.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate risk-based criteria and guidance for admission to the transitional area
Wider context from the report “During the inquest I heard evidence of a cut off weight for babies to go into a transitional area where they will receive more careful monitoring. Currently the guideline is babies weighing over 2.5kg do not need to go into this unit. ████████ a Consultant Neonatologist from the hospital gave evidence about this and indicated that there should be different weights for gestation and different guides for boys and girls. He also said that the presentation of the evidence would be better if it was graphically done and that by referring to a graph it would give a better understanding of a baby being at risk to the staff .
In addition ████████ said that there was a need to synthesize joint working with doctors and midwives. That there should be educational packages for hypoglycaemia and for recognising an unwell baby for both doctors and midwives with a measurement of competency.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of competency-assessed education on hypoglycaemia for doctors and midwives
Wider context from the report “During the inquest I heard evidence of a cut off weight for babies to go into a transitional area where they will receive more careful monitoring. Currently the guideline is babies weighing over 2.5kg do not need to go into this unit. ████████ a Consultant Neonatologist from the hospital gave evidence about this and indicated that there should be different weights for gestation and different guides for boys and girls. He also said that the presentation of the evidence would be better if it was graphically done and that by referring to a graph it would give a better understanding of a baby being at risk to the staff.
In addition ████████ said that there was a need to synthesize joint working with doctors and midwives. That there should be educational packages for hypoglycaemia and for recognising an unwell baby for both doctors and midwives with a measurement of competency.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish effective joint working between doctors and midwives
Wider context from the report “During the inquest I heard evidence of a cut off weight for babies to go into a transitional area where they will receive more careful monitoring. Currently the guideline is babies weighing over 2.5kg do not need to go into this unit. ████████ a Consultant Neonatologist from the hospital gave evidence about this and indicated that there should be different weights for gestation and different guides for boys and girls. He also said that the presentation of the evidence would be better if it was graphically done and that by referring to a graph it would give a better understanding of a baby being at risk to the staff.
In addition ████████ said that there was a need to synthesize joint working with doctors and midwives . That there should be educational packages for hypoglycaemia and for recognising an unwell baby for both doctors and midwives with a measurement of competency.
” Open source report
27 Sep 2013 Rose Jean COLES · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Inadequate communication between the neonatal intensive care and cardiac units View source Failure of the cardiac unit to provide care suited to premature babies 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
Rose Jean COLES · 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
Rose Coles was born prematurely at 34 weeks’ gestation and had congenital heart disease for which she received treatment. Evidence raised concerns about communication between the neonatal intensive care unit and cardiac unit, including whether the cardiac unit was suited to caring for premature babies and whether a protocol, checklist or improved communication would assist staff.
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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between the neonatal intensive care and cardiac units
Wider context from the report “Evidence was given about the communication between the neonatal intensive care unit and the cardiac unit. Concerns were raised that the cardiac unit were not suited to caring for premature babies and that a protocol or checklist or better communication between NICU and cardiac unit would be helpful to assist the doctors and indeed the nurses in caring for a premature baby on the cardiac ward.
” 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 Bristol NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the cardiac unit to provide care suited to premature babies
Wider context from the report “Evidence was given about the communication between the neonatal intensive care unit and the cardiac unit. Concerns were raised that the cardiac unit were not suited to caring for premature babies and that a protocol or checklist or better communication between NICU and cardiac unit would be helpful to assist the doctors and indeed the nurses in caring for a premature baby on the cardiac ward.
” 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 structured cardiac transfer pack for use between the NICU and Cardiac Unit.
Verbatim wording from the response “Improve formal communication between NICU and Cardiac Unit. | RIC | Develop Structured Cardiac Transfer Pack for use between two units. | ████████ | 30th November 2013” Source location 2013-0245-Response-by-University-Hospital-Bristol
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 Circulate the NICU/BCH link consultant rota regularly to the Cardiac Unit.
Verbatim wording from the response “| RIC | Confirm NICU/BCH link consultant through regular circulation of rota to cardiac ward. | ████████ | 28th October 2013” Source location 2013-0245-Response-by-University-Hospital-Bristol
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 premature-infant feeding guidance and train appropriate staff on the paediatric cardiac ward.
Verbatim wording from the response “Facilitate care of premature infant on cardiac ward if appropriate for baby to be there. | RIC | Provide feeding guideline for premature infants and appropriate staff training to paediatric cardiac ward. | ████████ | 30th November 2013” Source location 2013-0245-Response-by-University-Hospital-Bristol
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 24-hour telephone access to the NICU nurse in charge for Cardiac Unit staff seeking advice.
Verbatim wording from the response “| RIC | Confirm NICU nurse in charge available 24 hours per day for telephone advice if requested to all cardiac ward staff. | ████████ | 28th October 2013” Source location 2013-0245-Response-by-University-Hospital-Bristol
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Addressed to North Bristol NHS Trust, now represented here by Bristol NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations