23 Mar 2016 June Elsie Parkes · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 11 Failure of transfer guidance to ensure timely transfer of patients requiring out-of-hours endoscopy View source Unavailability of urgent or emergency surgery for upper GI bleeds out of hours View source Deficient doctor record keeping View source Deficient nursing staff record keeping View source Failure of nursing staff to accurately score vital signs in the NEWS system View source Failure of nursing staff to recognise and implement recommended NEWS escalation measures View source Lack of protocol guidance for suspected upper GI bleeds in hours View source Lack of criteria for doctor presence during ambulance transfer of critically ill patients View source Lack of protocol guidance for identifying post-endoscopy rebleeding View source Delays in undertaking urgent or emergency endoscopies in hours View source Unavailability of urgent or emergency endoscopy out of hours View source See 8 more concerns
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AI-generated summary
June Elsie Parkes · 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
June Elsie Parkes became unwell with symptoms of an upper gastrointestinal bleed and was admitted to hospital on 14 December 2014. She later deteriorated and died shortly after being transferred to Huddersfield Royal Infirmary on 17 December 2014. The concerns included delays and gaps in systems for urgent or emergency endoscopy and surgery, monitoring and escalation, record keeping, and the transfer of critically ill patients.
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 Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of transfer guidance to ensure timely transfer of patients requiring out-of-hours endoscopy
Wider context from the report “(2) There is no provision at Calderdale Royal Hospital to undertake urgent or emergency endoscopies “out of hours”, if a patient is deemed to require such procedure and transfer to Huddersfield Royal Infirmary is required.
In light of no facility to undertake out of hours endoscopies, a number of doctors who gave evidence at the inquest, stated that present protocol guidance results in patients often being transferred in a critical condition , and there appeared to be a generalised view that if such facilities were not available 24 hours a day, the time to transfer such patients was when a further rebleed was suspected and whilst the patient remained stable
” 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 Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of urgent or emergency surgery for upper GI bleeds out of hours
Wider context from the report “(3) There is presently no provision at Calderdale Royal Hospital to undertake urgent/emergency surgery if deemed necessary, for patients with upper GI bleeds at Calderdale Royal Hospital “out of hours” . The comments made in the final paragraph of B also applies to this point.
” 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 Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Deficient doctor record keeping
Wider context from the report “(6) Record keeping of doctors
” 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 Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Deficient nursing staff record keeping
Wider context from the report “(5) Record keeping of nursing staff
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Calderdale Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing staff to accurately score vital signs in the NEWS system
Wider context from the report “(4) Nursing staff compliance with the news system both in respect of accurately scoring each of the various vital signs , and recognising and implementing any escalation measures that are recommended .
” 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 Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing staff to recognise and implement recommended NEWS escalation measures
Wider context from the report “(4) Nursing staff compliance with the news system both in respect of accurately scoring each of the various vital signs, and recognising and implementing any escalation measures that are recommended .
” 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 Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of protocol guidance for suspected upper GI bleeds in hours
Wider context from the report “A. The provision and systems in place to identify and undertake urgent or emergency endoscopies at Calderdale royal hospital “in hours”
i) From the details set out in section 4, there appears to have been various issues which resulted in a significant length of time elapsing between Mrs Parkes being identified as requiring an urgent endoscopy, and it actually being carried out, which didn’t reflect the timescale recommended within current NICE guidance.
ii) The present protocol gives guidance for patients that present with a suspected upper GI bleed out of hours but does not provide guidance for “in hours”
iii) the present protocol does not provide guidance to identify a patient who may have suffered a rebleed post endoscopy and what measures should be considered
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Calderdale Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of criteria for doctor presence during ambulance transfer of critically ill patients
Wider context from the report “(7) The criteria for when a doctor should be present during ambulance transfer between Calderdale Royal Hospital and Huddersfield Royal Infirmary of a critically ill patient
” 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 Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of protocol guidance for identifying post-endoscopy rebleeding
Wider context from the report “A. The provision and systems in place to identify and undertake urgent or emergency endoscopies at Calderdale royal hospital “in hours”
i) From the details set out in section 4, there appears to have been various issues which resulted in a significant length of time elapsing between Mrs Parkes being identified as requiring an urgent endoscopy, and it actually being carried out, which didn’t reflect the timescale recommended within current NICE guidance.
ii) The present protocol gives guidance for patients that present with a suspected upper GI bleed out of hours but does not provide guidance for “in hours”
iii) the present protocol does not provide guidance to identify a patient who may have suffered a rebleed post endoscopy and what measures should be considered
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Calderdale Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in undertaking urgent or emergency endoscopies in hours
Wider context from the report “A. The provision and systems in place to identify and undertake urgent or emergency endoscopies at Calderdale royal hospital “in hours”
i) From the details set out in section 4, there appears to have been various issues which resulted in a significant length of time elapsing between Mrs Parkes being identified as requiring an urgent endoscopy, and it actually being carried out, which didn’t reflect the timescale recommended within current NICE guidance .
ii) The present protocol gives guidance for patients that present with a suspected upper GI bleed out of hours but does not provide guidance for “in hours”
iii) the present protocol does not provide guidance to identify a patient who may have suffered a rebleed post endoscopy and what measures should be considered
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Calderdale Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of urgent or emergency endoscopy out of hours
Wider context from the report “(2) There is no provision at Calderdale Royal Hospital to undertake urgent or emergency endoscopies “out of hours” , if a patient is deemed to require such procedure and transfer to Huddersfield Royal Infirmary is required.
In light of no facility to undertake out of hours endoscopies, a number of doctors who gave evidence at the inquest, stated that present protocol guidance results in patients often being transferred in a critical condition, and there appeared to be a generalised view that if such facilities were not available 24 hours a day, the time to transfer such patients was when a further rebleed was suspected and whilst the patient remained stable
” 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