Recipient

Cambridge University Hospitals NHS Foundation Trust

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First report 30 Apr 2021•Latest report 30 Apr 2021

Recipient record

Reports, concerns and published responses

Health and care · NHS trust. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
1

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

100%published responses found
1stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Cambridge University Hospitals NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Cambridgeshire and Peterborough

    AI-generated summary

    Alvin Roy Black · 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

    Alvin Roy Black, a serving prisoner, died after developing breathing difficulties and chest pains two days after returning from hospital spinal surgery. He suffered a fatal pulmonary embolism and cardiac arrest despite CPR. Concerns included poor hygiene in the prison Health Care Centre and a missed opportunity to review whether anti-coagulation therapy should have been provided after surgery.

    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 Cambridge University Hospitals NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain adequate hygiene and deep cleaning in non-clinical Health Care Centre areas

    Wider context from the report

    “(1) Extensive evidence was heard concerning the poor state of cleanliness of the Health Care Centre at the Prison. Evidence confirmed that the ground floor of the Health Care Centre was not part of the clinical areas for which the Northamptonshire NHS Foundation Trust, the providers of health care at the Prison, were responsible: this area remained the responsibility of the Ministry of Justice. Whilst Health Care patients would regularly be located there, designated ‘vulnerable prisoners’ were also routinely resident in this location and, in respect of this cohort, there would be both a high turnover and sometimes challenging hygiene issues accompanying them. The evidence confirmed that the levels of hygiene in the common ways, kitchens, sinks, showers and the cells was poor and that this was of concern to prisoner patients and medical staff alike. Evidence also confirmed that no ‘deep cleans’ took place in these areas save where blood, vomit or a ‘dirty protest’ was specifically involved. I am concerned that such poor levels of hygiene give rise to the risk of prisoners returning from surgery, with perhaps compromised immune systems, facing a significant risk of infection, itself giving rise to a risk of future death. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridge University Hospitals NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct required VTE risk reviews for anti-coagulation decisions

    Wider context from the report

    “(2) Evidence disclosed, and was conceded by the Trust, that there had been a missed opportunity for consideration of whether or not anti-coagulation therapy should have been provided to Mr Black following the decision that he remain in Addenbrookes Hospital over-night on the 13th November following his surgery. Although she had been prompted by a pharmacist to review the VTE risk once the decision had been made that it was “unsafe” to discharge Mr Black on the afternoon of the 13th, the Senior House Officer involved failed to conduct the review as required by both NICE and Trust policy. Although this was on the face of it an individual failure by the SHO, I am concerned that (a) the system in place at the time did not pick up on this error; (b) that the SHO’s evidence indicated that the course she took was, in her experience, standard practice; and (c) in different clinical circumstances, the failure to ensure that the appropriate review took place gives rise to the risk of future (preventable) death. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cambridge University Hospitals NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the clinical system to detect missed VTE risk reviews

    Wider context from the report

    “(2) Evidence disclosed, and was conceded by the Trust, that there had been a missed opportunity for consideration of whether or not anti-coagulation therapy should have been provided to Mr Black following the decision that he remain in Addenbrookes Hospital over-night on the 13th November following his surgery. Although she had been prompted by a pharmacist to review the VTE risk once the decision had been made that it was “unsafe” to discharge Mr Black on the afternoon of the 13th, the Senior House Officer involved failed to conduct the review as required by both NICE and Trust policy. Although this was on the face of it an individual failure by the SHO, I am concerned that (a) the system in place at the time did not pick up on this error; (b) that the SHO’s evidence indicated that the course she took was, in her experience, standard practice; and (c) in different clinical circumstances, the failure to ensure that the appropriate review took place gives rise to the risk of future (preventable) death. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

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

How actions were described at the time

This respondent
100%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

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

Types of action described in responses

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

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

Data last updated 7 September 2026