28 Aug 2025 Kore Elizabeth Padgett · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 6 Failure to assess the risks and benefits of collar use and support an informed decision View source Lack of staff training in correct fitting of hard collars View source Failure of ward care professionals to communicate concerns about the health impact of collar use View source Lack of a multidisciplinary approach to treatment options and further assessments View source Failure by those in charge of care to consider concerns about the impact of collar use View source Failure of treating clinicians to communicate with the neurosurgical team about treatment options View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kore Elizabeth Padgett · 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
Kore Elizabeth Padgett was admitted to hospital after an accidental fall down the stairs, sustaining an unstable neck fracture requiring immobilisation in a hard collar. The collar affected her swallowing, contributed to pressure sores, and limited chest physiotherapy; she later developed recurrent aspiration pneumonia and died on 23 October 2024. The concerns included inadequate staff training in fitting the collar, insufficient communication and multidisciplinary consideration of treatment options, and a lack of opportunity for Kore to make an informed decision about the risks and benefits of continued collar use.
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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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess the risks and benefits of collar use and support an informed decision
Wider context from the report “iii) The absence of any consideration of the risks versus benefits of wearing the collar and consequently the lack of opportunity for Kore to consider the risk versus benefits and make an informed decision as to how she wanted to proceed.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training in correct fitting of hard collars
Wider context from the report “i) The absence of training for staff on the ward in respect of the correct fitting of a hard collar ;
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ward care professionals to communicate concerns about the health impact of collar use
Wider context from the report “iv) The lack of communication between professionals providing care on the ward and the concerns they were raising as to the impact of the collar upon Kore's health and the absence of any consideration of those concerns by those in charge of Kore’s care with no multi-disciplinary approach as to the available treatment options or further assessments which could have been undertaken.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a multidisciplinary approach to treatment options and further assessments
Wider context from the report “iv) The lack of communication between professionals providing care on the ward and the concerns they were raising as to the impact of the collar upon Kore's health and the absence of any consideration of those concerns by those in charge of Kore’s care with no multi-disciplinary approach as to the available treatment options or further assessments which could have been undertaken .
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by those in charge of care to consider concerns about the impact of collar use
Wider context from the report “iv) The lack of communication between professionals providing care on the ward and the concerns they were raising as to the impact of the collar upon Kore's health and the absence of any consideration of those concerns by those in charge of Kore’s care with no multi-disciplinary approach as to the available treatment options or further assessments which could have been undertaken.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of treating clinicians to communicate with the neurosurgical team about treatment options
Wider context from the report “ii) The absence of communication by the treating clinicians with the neurosurgical team at Leeds in respect of treatment options for Kore given the significant impact that the wearing of the collar was having on Kore with the development of pressure sores, difficulties with her swallow and increasing risks of aspiration.
” 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 competency-based neck-collar application, monitoring and management training to relevant ward clinical staff.
Verbatim wording from the response “orthopaedic wards) to support continuity of care and operational efficiency. To ensure safe and effective treatment, competency-based training will be provided to all clinical professionals involved in their care, including Registered Nurses, Allied Health Professionals, and substantive ward based Medical Staff. Led by ████████ (Senior Clinical Orthotist) and ████████ (Outpatient Therapy Services Manager), the training focuses on validated competency in the application, monitoring, and management of neck collars. Two sessions have been scheduled for Ward 19 staff in December 2025, with further sessions planned for Ward 21 staff in January 2026. Compliance will be monitored through annual audits, beginning one month after training implementation. The initiative remains on track for completion by the end of January 2026.” Source location Response from Calderdale and Huddersfield 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 Revise clinical guidance and protocols to establish escalation processes for advice, complications and neurosurgical liaison in cervical spine injury care.
Verbatim wording from the response “To support this pathway, CHFT guidance and protocols are being revised to provide clear escalation processes for clinical advice, complications and neurosurgical liaison and involvement relating to cervical spine injury. These revisions are being led by Dr ████████, Consultant in Care of the Elderly, and will ensure that patients are managed consistently in line with updated standards. This work is also scheduled for completion by November 2025 and is progressing as planned.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a cervical-spine pathway directing patients to dedicated acute orthopaedic wards with coordinated orthogeriatric and multidisciplinary support.
Verbatim wording from the response “The Trust has taken proactive and comprehensive steps to ensure the safe and consistent care of patients with cervical spine injuries. In response to concerns raised, we have developed a robust clinical pathway to guide admission, and treatment within dedicated acute orthopaedic wards. This pathway ensures that patients are consistently placed in clinical areas with the appropriate skills and resources to support all aspects of their care. The pathway also incorporates coordinated support from ortho-geriatricians and the multidisciplinary team (MDT). An ongoing audit is evaluating the admitting ward allocation, treatment, and patient outcomes. This work is led by ████████ Consultant and Divisional Director for Surgery and Anaesthetics, and ████████ Consultant and Clinical Director for Acute Medicine, and is on track for delivery by November 2025.” Source location Response from Calderdale and Huddersfield 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 Revise electronic care plans to document collar-related risk-benefit discussions and informed consent.
Verbatim wording from the response “In addition, CHFT is further embedding person-centred care principles to support informed consent when a patient has a collar in place. Led by ████████, Associate Director of Nursing for Surgery and Anaesthetics and Matron ████████, care plans are being revised to ensure that discussions around risk and benefit are documented clearly within the Electronic Patient Record (EPR). This initiative will be monitored through EPR audits and Quality Assurance Leadership walk rounds and is scheduled for completion by January 2026.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement a collar initiation and management procedure covering consent, risk-benefit decisions, neurosurgical input and escalation.
Verbatim wording from the response “A Standard Operating Procedure (SOP) for collar initiation and management is also being developed. This SOP will include guidance on consent, risk versus benefit, informed decision-making, collaborative input from the neurosurgical team, and clear escalation protocols. Led by Dr ████████, Matron for Surgery and Anaesthetics, the SOP will be embedded within the competency framework and is scheduled for implementation by the end of January 2026.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust
Open published response
14 Jul 2025 Myles Edward Scriven · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 4 Failure to audit the impact and outcomes of learning disability and autism training and provision View source Failure to act on relevant electronic patient record entries across clinical colleagues View source Lack of required adjustments for patients with learning disabilities and autism View source Failure to apply Mental Capacity Act principle 2 in clinical decision-making View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 11
Action
Establish a Quality Assurance Group reporting to the Board subcommittee to oversee care standards and record-keeping compliance.
Stated plannedThe respondent said that this action was planned when they made their response on 17 July 2025. View source
Action
Pilot and roll out patient-centred bedside boards across all areas, with evaluation of their impact.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025. View source
Action
Use standardised ward audits and direct engagement to verify standards, care-plan and passport use, and timely critical medication administration.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Revise the learning-disability care plan and support implementation with training on completion expectations.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025. View source
Action
Develop a monthly audit of Mental Capacity Act application for patients with learning disabilities.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025. View source
Action
Undertake weekly detailed audits of learning-disability care, including involvement, senior review and specialist recommendations.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Revise quality-improvement governance so divisions set measurable priorities and representatives are accountable for delivery.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Enhance Learning Disabilities and Mental Capacity Act content in induction and preceptorship, and develop clinical bite-sized learning and briefings.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025. View source
Action
Conduct weekend senior nursing leadership reviews across both hospital sites to assure sustained improvement.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2025. View source
Action
Reinforce Mental Capacity Act principles 1 and 2 through training and monitor application through the revised audit programme.
Stated plannedThe respondent said that this action was planned when they made their response on 17 July 2025. View source
Action
Further develop the learning-disability dashboard to support patient identification, care prioritisation, audit compliance and oversight.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025. View source See 8 more actions
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AI-generated summary
Myles Edward Scriven · 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
Myles Edward Scriven died at Huddersfield Royal Infirmary on 16 April 2023. The report states that lack of adjustments for his Autism and Learning Disabilities contributed to incorrect decisions about his care and medication. The principal concern was that existing training, policies and support arrangements were not effectively applied or audited to ensure safe care and medication decisions.
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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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to audit the impact and outcomes of learning disability and autism training and provision
Wider context from the report “(brief summary of matters of concern)
The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work . To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied . However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter. Clinicians were applying Mental Capacity Act principle 1 but not 2. ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when?
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on relevant electronic patient record entries across clinical colleagues
Wider context from the report “(brief summary of matters of concern)
The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work. To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied. However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter . Clinicians were applying Mental Capacity Act principle 1 but not 2. ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when?
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of required adjustments for patients with learning disabilities and autism
Wider context from the report “(brief summary of matters of concern)
The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work. To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied. However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter. Clinicians were applying Mental Capacity Act principle 1 but not 2. ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when?
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply Mental Capacity Act principle 2 in clinical decision-making
Wider context from the report “(brief summary of matters of concern)
The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work. To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied. However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just not acted upon by colleagues and had zero effect when he went on leave thereafter. Clinicians were applying Mental Capacity Act principle 1 but not 2 . ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is - how it is proposed to ensure full compliance with best practice and by when?
” 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 a Quality Assurance Group reporting to the Board subcommittee to oversee care standards and record-keeping compliance.
Verbatim wording from the response “The Chief Nurse will be chairing a new Quality Assurance Group from September 25 that will report directly into a sub committee of the board. This group will be responsible for oversight of compliance against expected standards of care for all patients including effective record keeping. Findings from the revised audit program will be fed into this group for action.” Source location Response from Calderdale and Huddersfield 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 Pilot and roll out patient-centred bedside boards across all areas, with evaluation of their impact.
Verbatim wording from the response “We have a Patient Centred Care Group that is a sub - group of the Patient Experience and Involvement Group. This group is led by an Associate Director of Nursing and is responsible for the development of evidence based practice in relation to the delivery of person centred care. We are currently piloting ‘behind the bed boards’ to replace existing boards. These boards describe what is important to patients and provide an opportunity for patients and families to capture key information, questions or concerns for their clinical team. The boards also act as a prompt for patients, relatives and our teams to capture important information in relation to reasonable adjustments or care needs. The boards will be rolled out across all areas by December 2025 with an associated plan to evaluate their impact.” Source location Response from Calderdale and Huddersfield 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 Use standardised ward audits and direct engagement to verify standards, care-plan and passport use, and timely critical medication administration.
Verbatim wording from the response “Through a standardised audit process (incorporating the national 15 steps challenge of seeing care through patient and relative eyes) and direct ward engagement, nursing leaders verify compliance with legal and regulatory standards, ensure consistent use of care plans and hospital passports, and promote timely administration of critical medications for patients with a learning disability. This provides the opportunity to resolve any issues identified at the point of care with feedback given in real time to the team involved.” Source location Response from Calderdale and Huddersfield 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 Revise the learning-disability care plan and support implementation with training on completion expectations.
Verbatim wording from the response “We have already identified through our enhanced audit program that changes are needed to the current learning disability care plan. ████████ is working with our Chief Nursing Information Officer and stakeholders across Bradford and Airedale, who share our clinical record system, to revise the content and approach to completion of this care plan. This will be supported through a training program that clearly describes expectations for completion. Once the care plan is live in our electronic patient record the results will be added to our quality assurance dashboard for oversight and action.” Source location Response from Calderdale and Huddersfield 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 Develop a monthly audit of Mental Capacity Act application for patients with learning disabilities.
Verbatim wording from the response “We are developing a monthly audit that will focus on application of the mental capacity act for patients with a learning disability that will be undertaken by our medical lead for learning disabilities and nurse consultant. This audit will be managed through existing governance structures but importantly will be used as an opportunity to recognise themes and trends and address practice at an individual level.” Source location Response from Calderdale and Huddersfield 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 Undertake weekly detailed audits of learning-disability care, including involvement, senior review and specialist recommendations.
Verbatim wording from the response “A more detailed audit is undertaken for patients with a learning disability on a weekly basis that provides an in-depth review of the care being delivered, focusing on patient, family and carer involvement and evidence of a senior review and implementation of any specialist recommendations. The findings from these audits will be discussed at the monthly Quality Assurance Group as well as the Learning Disabilities Group.” Source location Response from Calderdale and Huddersfield 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 Revise quality-improvement governance so divisions set measurable priorities and representatives are accountable for delivery.
Verbatim wording from the response “The approach to quality improvement has been revised to ensure that each division describes priorities with measurable actions that can be monitored in relation to impact and effectiveness. Representatives will be held to account for delivery of priorities through this group.” Source location Response from Calderdale and Huddersfield 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 Enhance Learning Disabilities and Mental Capacity Act content in induction and preceptorship, and develop clinical bite-sized learning and briefings.
Verbatim wording from the response “We are enhancing the Learning Disabilities and Mental Capacity Act training into Trust induction and preceptorship training for all staff groups and reviewing the existing training offer in Safeguarding and other training sessions that can should reference learning disability awareness. We recognise that this area requires ongoing focus and attention and are developing an approach to learning that will be delivered in the clinical setting such as bite sized learning and 7-minute briefings.” Source location Response from Calderdale and Huddersfield 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 Conduct weekend senior nursing leadership reviews across both hospital sites to assure sustained improvement.
Verbatim wording from the response “We recognise through this process that audits in real time are required to address issues and provide ongoing assurance that the care is delivered in line with local and national standards. As highlighted in Ms McKie’s evidence, senior nursing leadership reviews now take place every weekend across both Huddersfield and Calderdale hospital sites. These reviews provide assurance that sustained improvements are being made.” Source location Response from Calderdale and Huddersfield 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 Reinforce Mental Capacity Act principles 1 and 2 through training and monitor application through the revised audit programme.
Verbatim wording from the response “Although we have a robust Mental Capacity Act policy that is aligned to national standards, we recognise that this needs strengthening in relation to the application of principles 1 and 2. This will be reinforced through training and monitored through the revised audit program which will focus on the 3 key principles in relation to this.” Source location Response from Calderdale and Huddersfield 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 Further develop the learning-disability dashboard to support patient identification, care prioritisation, audit compliance and oversight.
Verbatim wording from the response “To support clinical oversight of patients with learning disabilities we are further developing the learning disability dashboard within KP+ (Qlik Sense) digital system. This is a data analytics/reporting tool which has the LD flag built into reporting fields which allows the Trust to identify patients with a learning disability so that clinical teams can use this data to allow prioritisation of care needs and oversight of care delivery.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust
Open published response
3 Apr 2022 Edward Arthur AKROYD · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 14 Failure to undertake second-midwife fresh eyes review View source Failure of internal review to investigate communication failures View source Failure to obtain available laboratory results for treatment planning View source Failure to undertake timely fresh eyes review View source Failure to communicate laboratory results to treating clinicians View source Failure to complete handover records in patients’ notes View source Failure to undertake timely blood pressure monitoring View source Failure to review earlier clinical records View source Failure to continue regular blood pressure monitoring and escalation View source Failure to accurately assess significantly elevated blood pressure View source Failure to provide a comprehensive clinical summary View source Failure of registrar to review medical notes and records View source Lack of awareness of recommended treatment for elevated blood pressure in labour View source Failure to recognise non-reassuring CTG signs View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action. 8
Position
The midwife’s reviewed practice and the registrar’s timely assessment are considered sufficient to address the fresh-eyes review concern.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Labour care is holistic, so other clinical priorities may justify not strictly following observation timings; earlier observations may not have detected raised blood pressure.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
The established requirement for transferring midwives to document structured handovers, supported by SBAR systems and training, is considered sufficient.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Existing guidance, training, governance review and feedback arrangements are considered sufficient to address compliance with maternal monitoring and fresh-eyes reviews.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
The doctor’s reflection, assessment, training, subsequent practice and case reviews are considered sufficient to establish competency in managing obstetric emergencies and related concerns.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Automatic laboratory-result availability in the primary record is considered sufficient, removing the need for results to be phoned through or verbally passed on.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
The Trust considers the doctor’s changed practice, including proactive information review and communication training, sufficient to address handover and record-review concerns.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
The internal investigation could not pursue why laboratory results were not passed on because the recipient could not be identified.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action. View source See 7 more positions
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AI-generated summary
Edward Arthur AKROYD · 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
Edward Arthur Akroyd was delivered by forceps on 13 January 2018 at Calderdale Royal Hospital after concerns arose during his mother’s labour, including pre-eclampsia and abnormal CTG tracing. He was transferred to Leeds General Infirmary for intensive treatment and died there on 17 January 2018. The principal concerns included inadequate monitoring and treatment of his mother’s elevated blood pressure, incomplete handover and medical records, failure to communicate laboratory results, and delayed recognition and interpretation of non-reassuring CTG findings.
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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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake second-midwife fresh eyes review
Wider context from the report “10. From the evidence presented, and in accordance with trust guidelines, a second midwife should have undertaken a fresh pair of eyes review at 18.40 hours, this did not occur . I understand that such guidelines are put in place so as to ensure that key features are not missed and appropriate treatment plans are put in place. I am concerned that if such reviews do not occur it presents a risk to the wellbeing of expectant mothers and their unborn child
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of internal review to investigate communication failures
Wider context from the report “3. After a diagnosis of pre-eclampsia was made at Huddersfield birthing centre and Prior to transfer, various samples were obtained and sent for laboratory analysis, some of the results were received at Huddersfield Birthing Centre and phoned through to the labour ward at Calderdale Royal Hospital. From the evidence presented, the results were not passed to Mrs Akroyds attendant midwife or treating registrar. The subsequent internal review did not appear to investigate and determine the reason why this did not occur .
I am concerned that if this were to reoccur, important information may not be provided which could pose a risk to the wellbeing of an expectant mother and their unborn child
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain available laboratory results for treatment planning
Wider context from the report “9. The same registrar stated in evidence that he was aware that samples had been taken at Huddersfield Birthing Centre but didn’t think there was a need to obtain the results to assist in determining an appropriate treatment plan. I am concerned that if similar circumstances were to reoccur it may pose a risk to the wellbeing of the expectant mother and their unborn child.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake timely fresh eyes review
Wider context from the report “1. Whilst Mrs Akroyd was being cared for at Huddersfield Birthing Centre, her blood pressure was not checked and fresh eyes review was not undertaken at the appropriate time in accordance with the trust guidance. I am concerned that if this were to reoccur there is a real risk of missed opportunities to identify significant changes which could impact upon both the mother and unborn baby’s wellbeing.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate laboratory results to treating clinicians
Wider context from the report “3. After a diagnosis of pre-eclampsia was made at Huddersfield birthing centre and Prior to transfer, various samples were obtained and sent for laboratory analysis, some of the results were received at Huddersfield Birthing Centre and phoned through to the labour ward at Calderdale Royal Hospital. From the evidence presented, the results were not passed to Mrs Akroyds attendant midwife or treating registrar . The subsequent internal review did not appear to investigate and determine the reason why this did not occur.
I am concerned that if this were to reoccur, important information may not be provided which could pose a risk to the wellbeing of an expectant mother and their unborn child
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete handover records in patients’ notes
Wider context from the report “2. At the time of transfer of care between midwives, following arrival at Calderdale Royal hospital, the attendant midwife did not enter a complete handover record in Mrs Akroyds notes , as she understood that it was the duty of the receiving midwife to make a record within the notes. At the inquest, the same midwife who continues to practise, gave evidence that she remained of the view that that was trust policy. The lack of entry in the notes led to confusion and a lack of clarity of the previously prescribed medication I heard evidence at the inquest, that the practise undertaken by the midwife was not trust policy at the time nor subsequently and it is the role of the midwife handing over care to complete a medical record within the patients notes . I am concerned that if complete and effective medical notes and records are not made, this may impact on decision making and treatment and in turn to the wellbeing of expectant mothers and their unborn child.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake timely blood pressure monitoring
Wider context from the report “1. Whilst Mrs Akroyd was being cared for at Huddersfield Birthing Centre, her blood pressure was not checked and fresh eyes review was not undertaken at the appropriate time in accordance with the trust guidance. I am concerned that if this were to reoccur there is a real risk of missed opportunities to identify significant changes which could impact upon both the mother and unborn baby’s wellbeing.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review earlier clinical records
Wider context from the report “4. In evidence, Mrs Akroyd attendant midwife at Calderdale Royal Hospital did not appear to acknowledge that there was a need for her to continue to undertake regular monitoring of Mrs Akroyds Blood pressure in light of earlier readings and to escalate to either a doctor or labour ward co-ordinator, I am concerned that if similar circumstances were to re-occur, this poses a risk to the wellbeing of expectant mother and her unborn child. The same midwife also in evidence appeared to state that there was no need to review Mrs Akroyds earlier records as a verbal handover had been made, once again I am concerned that if this were to reoccur, it may pose a risk to the wellbeing to expectant mother and child.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to continue regular blood pressure monitoring and escalation
Wider context from the report “4. In evidence, Mrs Akroyd attendant midwife at Calderdale Royal Hospital did not appear to acknowledge that there was a need for her to continue to undertake regular monitoring of Mrs Akroyds Blood pressure in light of earlier readings and to escalate to either a doctor or labour ward co-ordinator , I am concerned that if similar circumstances were to re-occur, this poses a risk to the wellbeing of expectant mother and her unborn child. The same midwife also in evidence appeared to state that there was no need to review Mrs Akroyds earlier records as a verbal handover had been made, once again I am concerned that if this were to reoccur, it may pose a risk to the wellbeing to expectant mother and child.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately assess significantly elevated blood pressure
Wider context from the report “5. The registrar who was seized of Mrs Akroyds care following transfer to Calderdale Royal hospital, in evidence stated that both at the time and also from the position of hindsight, considered Mrs Akroyds blood pressure both prior to and post transfer was only marginally elevated and he based his treatment plan on this view. I heard evidence from various consultants, that Mrs Akroyds blood pressure was significantly elevated, which required urgent treatment and careful review . I am concerned that if similar circumstances were to reoccur, and the same clinician were to hold similar views this may pose a risk to the wellbeing of the expectant mother and unborn child.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a comprehensive clinical summary
Wider context from the report “8. The same registrar in evidence stated that at the time he initially assessed Mrs Akroyd he expected the attendant midwife to provide to him a full update and that there was no necessity for him to have undertaken a review of Mrs Akroyds Medical notes and records. The attendant midwife did not provide a comprehensive summary of Mrs Akroyds medical notes and records . I am concerned that if the same circumstances were to reoccur, there presents a risk to the expectant mother and unborn child.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of registrar to review medical notes and records
Wider context from the report “8. The same registrar in evidence stated that at the time he initially assessed Mrs Akroyd he expected the attendant midwife to provide to him a full update and that there was no necessity for him to have undertaken a review of Mrs Akroyds Medical notes and records . The attendant midwife did not provide a comprehensive summary of Mrs Akroyds medical notes and records. I am concerned that if the same circumstances were to reoccur, there presents a risk to the expectant mother and unborn child.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of recommended treatment for elevated blood pressure in labour
Wider context from the report “6. The same registrar in evidence stated that he was not aware of the recommended treatment for elevated blood pressure at this stage of labour and that he had recognised Mrs Akroyd had pre-eclampsia and that he understood that the appropriate treatment of pre-eclampsia was the delivery of the baby. I am concerned that if the same facts were to reoccur, and the same registrar were to adopt the same treatment plan within similar time scales, it may present a risk to the wellbeing of the expectant mother and her unborn child.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise non-reassuring CTG signs
Wider context from the report “7. The same registrar in evidence stated that it was his view at the time and also from the position of hindsight, that the ctg trace showed no significant cause for concern until shortly before he made the decision that Mrs Akroyd Should undergo a forceps delivery. I heard evidence from a number of consultants that the ctg trace from shortly after its commencement was showing non reassuring signs which should together with other facts have resulted in an earlier delivery of Edward and if this had occurred it is likely he would have survived.
I am concerned that if the same facts were to reoccur, and a similar interpretation of a ctg trace was to be made , it poses a risk to the expectant mother and her unborn child.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement structured SBAR handover documentation by transferring midwives, supported by a designated section in electronic patient records.
Verbatim wording from the response “This process remains the same. It is the responsibility of the transferring midwife to complete a documented structured (SBAR) handover in the clinical records, as well as giving a verbal handover. Since 2018 the Trust has done a lot of work within the Maternity Service and more widely on SBAR handovers, including what to document; where to put the information in the computer records and how to access the information. There is now a specific designated part of the computer records for the recording of the information.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
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 compulsory annual training for midwives and maternity staff covering CTG monitoring, maternal monitoring and obstetric emergencies.
Verbatim wording from the response “In terms of disseminating guidance, refreshing the knowledge of staff and monitoring compliance: All new and revised guidelines are placed on the Trust’s intranet and are available at any time electronically. The weekly Maternity Risk Management Newsletter will have a notice about new or revised guidelines. The compulsory annual Obstetric Emergency Training Day contains reminders about these guidelines.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
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 automatic transfer of laboratory results into the primary patient record and display them on the Trust-wide system home screen.
Verbatim wording from the response “The computer system for reporting results has changed since 2018. As soon as results are put onto the laboratory computer system those results are pulled through to the primary patient record and can then be seen on the “home” screen of the Trust wide system. Any doctor or midwife can therefore check on the blood test results, including remote access, for example, on an on call consultant accessing the system from home. This means there is no need for the results to be phoned through or passed on verbally.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement a standard operating procedure requiring hourly fresh-eyes clinical reviews in labour at the Birth Centre.
Verbatim wording from the response “The second issue is the fresh eyes review. The Trust’s Maternity Services regularly review and update local guidelines.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
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 midwife’s reviewed practice and the registrar’s timely assessment are considered sufficient to address the fresh-eyes review concern.
Verbatim wording from the response “A fresh eyes assessment should be undertaken by a second person qualified to assess the CTG. This does not have to be a midwife, an Obstetrician at registrar level would be regarded as suitably qualified to undertake a fresh eyes assessment. In this case the Registrar reviewed Mrs Akroyd at 18.53. This was however 13 minutes later than the best practice of 60 minutes.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
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 Labour care is holistic, so other clinical priorities may justify not strictly following observation timings; earlier observations may not have detected raised blood pressure.
Verbatim wording from the response “There are two issues here, although the concern with both is actions not being taken in accordance with timings in Guidance. It is important to say that care in labour should be a holistic process and that there are times when one aspect of care may take precedence over another even if that means the timings in guidelines are not strictly followed.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
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 established requirement for transferring midwives to document structured handovers, supported by SBAR systems and training, is considered sufficient.
Verbatim wording from the response “The lack of entry in the notes led to confusion and a lack of clarity of previously prescribed medication I heard evidence at the inquest, that the practise undertaken by the midwife was not trust policy at the time nor subsequently and it is the role of the midwife handing over care to complete a medical record within the patients notes.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing guidance, training, governance review and feedback arrangements are considered sufficient to address compliance with maternal monitoring and fresh-eyes reviews.
Verbatim wording from the response “The second issue is the fresh eyes review. The Trust’s Maternity Services regularly review and update local guidelines.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
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 doctor’s reflection, assessment, training, subsequent practice and case reviews are considered sufficient to establish competency in managing obstetric emergencies and related concerns.
Verbatim wording from the response “He has reflected on this case with his clinical supervisors and with a number of consultant colleagues. He has had annual appraisals and undergone the vigorous process of assessment and was awarded a CESR certificate and recognised on the specialist register by the GMC on 30 November 2020. Since his involvement in Mrs Akroyd’s care, he has since progressed to a substantive Consultant post at the Trust.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
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 Automatic laboratory-result availability in the primary record is considered sufficient, removing the need for results to be phoned through or verbally passed on.
Verbatim wording from the response “The computer system for reporting results has changed since 2018. As soon as results are put onto the laboratory computer system those results are pulled through to the primary patient record and can then be seen on the “home” screen of the Trust wide system. Any doctor or midwife can therefore check on the blood test results, including remote access, for example, on an on call consultant accessing the system from home. This means there is no need for the results to be phoned through or passed on verbally.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
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 Trust considers the doctor’s changed practice, including proactive information review and communication training, sufficient to address handover and record-review concerns.
Verbatim wording from the response “Please see the response to concern 5 above.” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
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 internal investigation could not pursue why laboratory results were not passed on because the recipient could not be identified.
Verbatim wording from the response “It should be noted that there was no diagnosis of pre-eclampsia at the Huddersfield Birthing Centre. High blood pressure was recognised. Nevertheless, the results of the blood tests should have been accurately passed on. It was not felt possible to pursue the matter in the” Source location Response from Calderdale and Huddersfield NHS Foundation Trust (1)
Open published response
21 Oct 2019 Sharon Jamela Reeve · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 9 Lack of clarity about appropriate use of the electronic referral portal View source Lack of clarity about the issues for which specialist guidance is sought View source Lack of clarity about information required in electronic referrals View source Slow image-transfer conduit preventing review of CT and MRI images View source Failure to specify the clinical questions in specialist referrals View source Referral routing failing to provide radiologists’ reports View source Lack of firm rules requiring image review before referral responses View source Lack of a prescribed direct-access pathway to neuroradiology specialists View source Failure to clarify missing referral information before responding View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sharon Jamela Reeve · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sharon Jamela Reeve developed a persistent headache, underwent investigations and was discharged after an electronic referral to a tertiary neurosurgical unit. She was found unresponsive on 10 March 2018, underwent emergency surgery and died on 14 March 2018. The principal concerns were unclear referral pathways, incomplete and ineffective communication between hospitals, delays in specialist review, and inadequate clarity about the electronic referral system.
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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about appropriate use of the electronic referral portal
Wider context from the report “(3) Evidence was heard at the Inquest to the effect that numerous inappropriate referrals are made to the tertiary neurosurgical unit . I am concerned that this may be due to a lack of clarity at the entrance to the electronic portal so as to: -
(a) Make plain the circumstances in which it should be used – and where it is not appropriate.
(b) The information required to be included.
(c) The precise issues upon which guidance is sought.
If relatively junior clinicians are likely to be involved in the interface between DGH and tertiary specialist centres, there may well be a training component to improve the quality of information and requests submitted.
It was said that the electronic referral system in use at Leeds General Infirmary Neurosurgical Unit in March 2018 has been replaced. As the Inquest was not provided with details of the replacement system, the court was not able to consider whether the concerns outlined here have been resolved.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the issues for which specialist guidance is sought
Wider context from the report “(3) Evidence was heard at the Inquest to the effect that numerous inappropriate referrals are made to the tertiary neurosurgical unit. I am concerned that this may be due to a lack of clarity at the entrance to the electronic portal so as to: -
(a) Make plain the circumstances in which it should be used – and where it is not appropriate.
(b) The information required to be included.
(c) The precise issues upon which guidance is sought.
If relatively junior clinicians are likely to be involved in the interface between DGH and tertiary specialist centres, there may well be a training component to improve the quality of information and requests submitted.
It was said that the electronic referral system in use at Leeds General Infirmary Neurosurgical Unit in March 2018 has been replaced. As the Inquest was not provided with details of the replacement system, the court was not able to consider whether the concerns outlined here have been resolved.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about information required in electronic referrals
Wider context from the report “(3) Evidence was heard at the Inquest to the effect that numerous inappropriate referrals are made to the tertiary neurosurgical unit. I am concerned that this may be due to a lack of clarity at the entrance to the electronic portal so as to: -
(a) Make plain the circumstances in which it should be used – and where it is not appropriate.
(b) The information required to be included.
(c) The precise issues upon which guidance is sought.
If relatively junior clinicians are likely to be involved in the interface between DGH and tertiary specialist centres, there may well be a training component to improve the quality of information and requests submitted.
It was said that the electronic referral system in use at Leeds General Infirmary Neurosurgical Unit in March 2018 has been replaced. As the Inquest was not provided with details of the replacement system, the court was not able to consider whether the concerns outlined here have been resolved.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Slow image-transfer conduit preventing review of CT and MRI images
Wider context from the report “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life.
The pertinent features of the miscommunication were:
1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists).
2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed.
3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them.
4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding.
5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to specify the clinical questions in specialist referrals
Wider context from the report “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life.
The pertinent features of the miscommunication were:
1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists).
2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed.
3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them.
4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding.
5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Referral routing failing to provide radiologists’ reports
Wider context from the report “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life.
The pertinent features of the miscommunication were:
1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists . This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists).
2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed.
3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them.
4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding.
5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of firm rules requiring image review before referral responses
Wider context from the report “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life.
The pertinent features of the miscommunication were:
1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists).
2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed.
3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them.
4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding.
5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a prescribed direct-access pathway to neuroradiology specialists
Wider context from the report “(1) The two consultant radiologists at the district general hospital saw a need for a specialist opinion to assist in the interpretation of complex and abnormal CT and MRI scans. There was no clear prescribed pathway for them to obtain direct access to neuroradiologists at the tertiary centre . In consequence, an inapposite referral was made to a neurosurgical unit, which did not assist the resolution of the uncertainties regarding the correct diagnosis. My concern is that if much needed linkages between relevant groups are not appreciated and made effective, then the value of having a specialist resource could be lost in future cases, not only in the medical specialty and hospital involved here, but in many others as well.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify missing referral information before responding
Wider context from the report “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life.
The pertinent features of the miscommunication were:
1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists).
2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed.
3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them.
4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding , even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding.
5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images.
” Open source report
16 Sep 2019 Tae’jelle Kaliyah Francois · Prevention of Future Deaths report West Yorkshire (West)
View report summary
Concerns raised 1 Failure to ensure timely visual assessment and escalation of seriously unwell patients at A&E admission 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
Tae’jelle Kaliyah Francois · 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
Tae’jelle Kaliyah Francois suffered an acute asthma attack that continued despite prescribed medicine. While travelling to hospital and waiting for admission, her condition deteriorated, she collapsed, and she died at Huddersfield Royal Infirmary despite resuscitation. The report raised concerns that she was taken to the Accident and Emergency waiting area without visual assessment by reception or triage staff, and that an opportunity to recognise and escalate her critical condition was missed.
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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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely visual assessment and escalation of seriously unwell patients at A&E admission
Wider context from the report “(1) At the point of admission into the Accident and Emergency Department, Tae’jelle was taken into the waiting area without either the Receptionist or the Triage nurse having the opportunity to visually assess her , despite Tae’jelle being in a medically critical state. Tae’jelle was taken into the waiting area of reception, where she stopped breathing.
It was only as a result of the intervention of a member of the public that this condition was discovered, and as a result of that involvement Tae’jelle was taken into the Resus Department, where further treatment failed to revive her.
(2) Evidence was given at the Inquest as to a Guidance recommended by The Royal College of Emergency Medicine upon dealing with the Emergency Assessment of Emergency patients. Such a Protocol provides for Reception to inform the Triage nurse of suspected seriously unwell patient, with the opportunity of then escalating the treatment of that patient .
(3) Evidence was given at the Inquest that this opportunity was missed as neither the receptionist nor the Triage Nurse were provided with the opportunity to make the necessary assessment , despite the fact that the Department was not busy at the time.
” Open source report
26 Jul 2019 Gladys May Sayles · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 3 Inadequate guidelines for the use of Aspen collars View source Inadequate training for applying and fixing collars to patients' needs View source Ineffective communications about collar fitting and patients' general care 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
Gladys May Sayles · 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
Gladys May Sayles was found collapsed after an unwitnessed fall at home and sustained fractures to her C2 and C3 vertebrae. She later received palliative treatment at Overgate Hospice and died there; concerns were identified about guidance, training and communication concerning the use and fitting of her hard collar.
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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate guidelines for the use of Aspen collars
Wider context from the report “• To review the existing guidelines with respect to the use of Aspen collars .
• To review training with respect to the application and fixing of the collar in order to make it bespoke to the patient's needs.
• To consider the effectiveness of the existing communications between Leeds General neurological unit, Huddersfield Royal Infirmary and the suppliers of the collar's with respect to the fitting of the collar and patients general care.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate training for applying and fixing collars to patients' needs
Wider context from the report “• To review the existing guidelines with respect to the use of Aspen collars.
• To review training with respect to the application and fixing of the collar in order to make it bespoke to the patient's needs .
• To consider the effectiveness of the existing communications between Leeds General neurological unit, Huddersfield Royal Infirmary and the suppliers of the collar's with respect to the fitting of the collar and patients general care.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective communications about collar fitting and patients' general care
Wider context from the report “• To review the existing guidelines with respect to the use of Aspen collars.
• To review training with respect to the application and fixing of the collar in order to make it bespoke to the patient's needs.
• To consider the effectiveness of the existing communications between Leeds General neurological unit, Huddersfield Royal Infirmary and the suppliers of the collar's with respect to the fitting of the collar and patients general care .
” Open source report
15 Dec 2015 Ruth Hilda Smith · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 6 Failure to carry out required hourly nursing observations View source Inadequate medical record keeping View source Failure to arrange follow-up medical review after a fluid challenge View source Delays in doctor attendance following a requested review View source Failure to chase up requested doctor attendance and review View source Inadequate nursing record keeping View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ruth Hilda Smith · 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
Ruth Hilda Smith died on 16 April 2014 at Huddersfield Royal Infirmary after developing a haemothorax following insertion of a central venous line, with sepsis, altered liver function and pneumonia also recorded as causes. Concerns included delays in medical review, inadequate nursing observations, and poor nursing and medical record keeping during the evening of 15 April and early hours of 16 April 2014.
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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out required hourly nursing observations
Wider context from the report “Nursing Care
At 22.05 Mrs Smith was found to have an elevated MEWS score and as a result a request was made for an FY 1 Doctor to review. Evidence was given by a senior charge nurse( who provided an overview of nursing care to Mrs Smith, but who was not directly involved in her care) that following this Mrs Smith should have undergone hourly observations.
This did not happen.
There was reference to observations being undertaken at 00.30 but these were not recorded.
Further observations were incomplete
The FY1 Doctor did not attend the ward until 00.30. There was no record within the notes to suggest that enquiries were undertaken between 22.30 and 00.30 to chase up the attendance of the FY 1 Doctor.
I have the following concerns:
1. No attempts were made to ensure a doctor attended and reviewed Mrs. Smith between 22.30 and 00.30.
2. The level of nursing monitoring (hourly observations) taking place for much of the period between 22.30 on the 15th April and 03.25 on the 16th April.
3. The standard of the nursing record keeping.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate medical record keeping
Wider context from the report “Medical Care
A doctor attended at 18.40 upon Mrs Smith but did not make a full record within the medical records.
Nursing staff requested a doctor review at 22.30 hours. No doctor attended until 00.30 hours.
When a doctor did attend a fluid challenge was implemented. The doctor did not return to review Mrs Smith or put in place arrangements for another doctor to review.
At 2.00 hours an FY2 doctor attended following a request by nursing staff. The FY2 doctor determined that Mrs Smith’s bloods and blood gases should be checked. I heard evidence that nursing staff advised the FY2 doctor that Mrs Smith needed more senior medical review by a registrar.
The FY2 made no entries within Mrs Smith’s medical records.
I have the following concerns:
1. The 2 hour time lapse between a request for a doctor review and a doctor attending upon Mrs.Smith.
2. No review was put in place following the implementation of the fluid challenge.
3. The standard of record keeping and lack of records being made by the doctors who attended up Mrs. Smith on the evening of the 15th April and early hours of the 16th April up until the Registrar’s involvement at 03.25 a.m. on the 16th April.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange follow-up medical review after a fluid challenge
Wider context from the report “Medical Care
A doctor attended at 18.40 upon Mrs Smith but did not make a full record within the medical records.
Nursing staff requested a doctor review at 22.30 hours. No doctor attended until 00.30 hours.
When a doctor did attend a fluid challenge was implemented. The doctor did not return to review Mrs Smith or put in place arrangements for another doctor to review.
At 2.00 hours an FY2 doctor attended following a request by nursing staff. The FY2 doctor determined that Mrs Smith’s bloods and blood gases should be checked. I heard evidence that nursing staff advised the FY2 doctor that Mrs Smith needed more senior medical review by a registrar.
The FY2 made no entries within Mrs Smith’s medical records.
I have the following concerns:
1. The 2 hour time lapse between a request for a doctor review and a doctor attending upon Mrs.Smith.
2. No review was put in place following the implementation of the fluid challenge.
3. The standard of record keeping and lack of records being made by the doctors who attended up Mrs. Smith on the evening of the 15th April and early hours of the 16th April up until the Registrar’s involvement at 03.25 a.m. on the 16th April.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in doctor attendance following a requested review
Wider context from the report “Medical Care
A doctor attended at 18.40 upon Mrs Smith but did not make a full record within the medical records.
Nursing staff requested a doctor review at 22.30 hours. No doctor attended until 00.30 hours.
When a doctor did attend a fluid challenge was implemented. The doctor did not return to review Mrs Smith or put in place arrangements for another doctor to review.
At 2.00 hours an FY2 doctor attended following a request by nursing staff. The FY2 doctor determined that Mrs Smith’s bloods and blood gases should be checked. I heard evidence that nursing staff advised the FY2 doctor that Mrs Smith needed more senior medical review by a registrar.
The FY2 made no entries within Mrs Smith’s medical records.
I have the following concerns:
1. The 2 hour time lapse between a request for a doctor review and a doctor attending upon Mrs.Smith.
2. No review was put in place following the implementation of the fluid challenge.
3. The standard of record keeping and lack of records being made by the doctors who attended up Mrs. Smith on the evening of the 15th April and early hours of the 16th April up until the Registrar’s involvement at 03.25 a.m. on the 16th April.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to chase up requested doctor attendance and review
Wider context from the report “Nursing Care
At 22.05 Mrs Smith was found to have an elevated MEWS score and as a result a request was made for an FY 1 Doctor to review. Evidence was given by a senior charge nurse( who provided an overview of nursing care to Mrs Smith, but who was not directly involved in her care) that following this Mrs Smith should have undergone hourly observations.
This did not happen.
There was reference to observations being undertaken at 00.30 but these were not recorded.
Further observations were incomplete
The FY1 Doctor did not attend the ward until 00.30. There was no record within the notes to suggest that enquiries were undertaken between 22.30 and 00.30 to chase up the attendance of the FY 1 Doctor.
I have the following concerns:
1. No attempts were made to ensure a doctor attended and reviewed Mrs. Smith between 22.30 and 00.30.
2. The level of nursing monitoring (hourly observations) taking place for much of the period between 22.30 on the 15th April and 03.25 on the 16th April.
3. The standard of the nursing record keeping.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate nursing record keeping
Wider context from the report “Nursing Care
At 22.05 Mrs Smith was found to have an elevated MEWS score and as a result a request was made for an FY 1 Doctor to review. Evidence was given by a senior charge nurse( who provided an overview of nursing care to Mrs Smith, but who was not directly involved in her care) that following this Mrs Smith should have undergone hourly observations.
This did not happen.
There was reference to observations being undertaken at 00.30 but these were not recorded.
Further observations were incomplete
The FY1 Doctor did not attend the ward until 00.30. There was no record within the notes to suggest that enquiries were undertaken between 22.30 and 00.30 to chase up the attendance of the FY 1 Doctor.
I have the following concerns:
1. No attempts were made to ensure a doctor attended and reviewed Mrs. Smith between 22.30 and 00.30.
2. The level of nursing monitoring (hourly observations) taking place for much of the period between 22.30 on the 15th April and 03.25 on the 16th April.
3. The standard of the nursing record keeping.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use Nerve Centre mobile observations to record patient observations, trigger escalation for raised NEWS scores, and monitor response trends.
Verbatim wording from the response “1. “Nerve Centre” – Nerve Centre is the use of mobile electronic observations and hospital at night software to improve patient safety and staff communication anywhere within our hospitals 24 hours a day, 7 days a week. All patient observations are recorded on an IPAD. The use of mobile technology also allows doctors and nurses to have all the tools and information at hand to be able to respond rapidly and effectively to deteriorating patients.” Source location Ruth-Smith-Response
Open published response
16 Apr 2015 Jeanne Elsie Summers · Prevention of Future Deaths report West Yorkshire (West)
View report summary
Concerns raised 6 Failure of physiotherapy records to contain all relevant details View source Failure of fall investigations to address preventability and identify relevant contributing factors View source Lack of assessment of patients’ ability prior to discharge View source Failure to maintain safe systems of transfer while patients are being transferred View source Failure to ensure appropriate footwear before patient mobilisation View source Lack of full training for staff undertaking investigations and preparing investigative reports View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jeanne Elsie Summers · 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
Jeanne Elsie Summers was admitted to hospital with an exacerbation of chronic obstructive pulmonary disease and infection, and later suffered an unwitnessed fall while mobilising to the toilet, resulting in an open right ankle fracture. She subsequently developed pneumonia and died on 24 July 2013. Concerns included the absence of a clear mobility assessment before discharge, incomplete physiotherapy records, unsuitable footwear and unsafe transfer practices, and inadequate investigation of the fall.
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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of physiotherapy records to contain all relevant details
Wider context from the report “(2) During the further readmission on the 7th July 2013 Mrs. Summers was reviewed on a number of occasions by a physiotherapist. At the inquest ████████ Clinical Lead Physiotherapist, provided evidence indicating that the physiotherapy written records did not provide a full record of all relevant details . These notes are reviewed by nursing staff in order to ensure the patient’s safe mobilisation and the preparation of appropriate care plans. I would ask you to consider that additional training and/or direction should be given to the Physiotherapy Department in order to ensure that a full record of all relevant details are made within patients’ records.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of fall investigations to address preventability and identify relevant contributing factors
Wider context from the report “(4) At the inquest Matron ████████ gave evidence in respect of an investigation which she undertook in respect of the circumstances surrounding Mrs. Summers’ fall. Matron ████████ indicated in her evidence that she had not received full training with regard to undertaking an investigation and preparing an investigative report.
Although in her report she stated that one of the objectives was to consider if the fall could have been prevented, that question was not addressed in her report. When questioned by me she confirmed in evidence that the socks which Mrs. Summers was wearing at the time of her fall and the fact that she was left before she had effectively safely transferred on to the toilet are likely to have been factors which would have caused, or significantly contributed to Mrs. Summers’ fall. Neither of these points were identified in the report. I would request that in future all investigators receive the appropriate training to enable them to undertake a full and appropriate 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of assessment of patients’ ability prior to discharge
Wider context from the report “(1) The assessment review of Mrs. Summers’ ability prior to her discharge on the 6th July 2013. There is no clear indication that an assessment had been undertaken prior to Mrs. Summers’ discharge on the 6th July 2013. Her condition was such that she required further readmission on the 7th July 2013.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain safe systems of transfer while patients are being transferred
Wider context from the report “(3) From the evidence presented at the inquest it appears that at the time when Mrs. Summers was mobilising in the early hours of the 14th July 2013 she was wearing her own “fluffy socks”. These were not slipper socks. She was clearly not wearing slippers at the time. In addition the health care assistant who was supervising Mrs Summers did not ensure that Mrs. Summers was seated on the toilet within the toilet cubicle before he left her.
I would request you to consider training and guidance to nursing staff to ensure that, firstly, patients are wearing appropriate footwear prior to mobilisation and, secondly, to provide training guidance to staff of safe systems of transfer to ensure that patients are not left whilst in the process of transfer .
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure appropriate footwear before patient mobilisation
Wider context from the report “(3) From the evidence presented at the inquest it appears that at the time when Mrs. Summers was mobilising in the early hours of the 14th July 2013 she was wearing her own “fluffy socks”. These were not slipper socks. She was clearly not wearing slippers at the time. In addition the health care assistant who was supervising Mrs Summers did not ensure that Mrs. Summers was seated on the toilet within the toilet cubicle before he left her.
I would request you to consider training and guidance to nursing staff to ensure that, firstly, patients are wearing appropriate footwear prior to mobilisation and, secondly, to provide training guidance to staff of safe systems of transfer to ensure that patients are not left whilst in the process of transfer.
” 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 Calderdale and Huddersfield NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of full training for staff undertaking investigations and preparing investigative reports
Wider context from the report “(4) At the inquest Matron ████████ gave evidence in respect of an investigation which she undertook in respect of the circumstances surrounding Mrs. Summers’ fall. Matron ████████ indicated in her evidence that she had not received full training with regard to undertaking an investigation and preparing an investigative report.
Although in her report she stated that one of the objectives was to consider if the fall could have been prevented, that question was not addressed in her report. When questioned by me she confirmed in evidence that the socks which Mrs. Summers was wearing at the time of her fall and the fact that she was left before she had effectively safely transferred on to the toilet are likely to have been factors which would have caused, or significantly contributed to Mrs. Summers’ fall. Neither of these points were identified in the report. I would request that in future all investigators receive the appropriate training to enable them to undertake a full and appropriate investigation.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations