Recipient

British Society of Paediatric Gastroenterology, Hepatology and Nutrition

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First report 20 Feb 2015•Latest report 20 Feb 2015

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Health professional body. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from British Society of Paediatric Gastroenterology, Hepatology and Nutrition linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. West Yorkshire Eastern

    AI-generated summary

    Lexie Louise Harrison · 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

    Lexie Louise Harrison, who had Infantile Refsum Disease, underwent an unsuccessful attempt to band an oesophageal varix on 30 May 2013, which caused trauma and extensive bleeding. Her condition deteriorated and she died at home on 18 June 2013; the medical cause of death was recorded as liver failure and Infantile Refsum Disease. The concerns included the absence of relevant policies or guidelines at two trusts and a lack of standardisation in practice, including decisions about banding, assessment, post-endoscopy care, management of bleeding, and consultant competence.

    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 British Society of Paediatric Gastroenterology, Hepatology and Nutrition; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of local policy and/or guidelines for paediatric endoscopic banding of oesophageal varices

    Wider context from the report

    “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years. (2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:- (a) Precise definitions of the grades of oesophageal varices; (b) Which grades of varices should be subject to banding and which should not; (c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not; (d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure; (e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations; (f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics; (g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision. ”
    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 British Society of Paediatric Gastroenterology, Hepatology and Nutrition; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to standardise Consultant practice for paediatric endoscopic banding of oesophageal varices

    Wider context from the report

    “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years. (2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:- (a) Precise definitions of the grades of oesophageal varices; (b) Which grades of varices should be subject to banding and which should not; (c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not; (d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure; (e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations; (f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics; (g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision. ”
    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 British Society of Paediatric Gastroenterology, Hepatology and Nutrition; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of defined Consultant competency and supervision criteria for the procedure

    Wider context from the report

    “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years. (2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:- (a) Precise definitions of the grades of oesophageal varices; (b) Which grades of varices should be subject to banding and which should not; (c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not; (d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure; (e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations; (f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics; (g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision. ”
    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 British Society of Paediatric Gastroenterology, Hepatology and Nutrition; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of standardised post-endoscopy care requirements

    Wider context from the report

    “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years. (2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:- (a) Precise definitions of the grades of oesophageal varices; (b) Which grades of varices should be subject to banding and which should not; (c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not; (d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure; (e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations; (f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics; (g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision. ”
    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 British Society of Paediatric Gastroenterology, Hepatology and Nutrition; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a defined pre-procedure assessment process for banding programme patients

    Wider context from the report

    “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years. (2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:- (a) Precise definitions of the grades of oesophageal varices; (b) Which grades of varices should be subject to banding and which should not; (c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not; (d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure; (e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations; (f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics; (g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision. ”
    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 British Society of Paediatric Gastroenterology, Hepatology and Nutrition; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of defined patient suitability criteria for banding programmes

    Wider context from the report

    “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years. (2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:- (a) Precise definitions of the grades of oesophageal varices; (b) Which grades of varices should be subject to banding and which should not; (c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not; (d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure; (e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations; (f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics; (g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision. ”
    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 British Society of Paediatric Gastroenterology, Hepatology and Nutrition; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of defined criteria for which varices should undergo banding

    Wider context from the report

    “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years. (2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:- (a) Precise definitions of the grades of oesophageal varices; (b) Which grades of varices should be subject to banding and which should not; (c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not; (d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure; (e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations; (f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics; (g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision. ”
    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 British Society of Paediatric Gastroenterology, Hepatology and Nutrition; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of defined assessment and management steps for variceal bleeding

    Wider context from the report

    “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years. (2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:- (a) Precise definitions of the grades of oesophageal varices; (b) Which grades of varices should be subject to banding and which should not; (c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not; (d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure; (e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations; (f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics; (g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision. ”
    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 British Society of Paediatric Gastroenterology, Hepatology and Nutrition; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of precise definitions of oesophageal varix grades

    Wider context from the report

    “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years. (2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:- (a) Precise definitions of the grades of oesophageal varices; (b) Which grades of varices should be subject to banding and which should not; (c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not; (d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure; (e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations; (f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics; (g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

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

How actions were described at the time

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

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

Types of action described in responses

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

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026