Cannock Chase Hospital

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First report 8 Nov 2024•Latest report 8 Nov 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Cannock Chase Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Staffordshire and Stoke-on-Trent

    AI-generated summary

    Gemma Louise Helen RALPH · 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

    Gemma Louise Helen Ralph, a Theatre Support Assistant at Cannock Chase Hospital, died at home on 26 January 2024 after inhaling the anaesthetic sevoflurane without intent to end her life. Concerns remained about the monitoring of sevoflurane bottles and the inability to confirm or refute whether the bottle found at her home originated from Cannock Chase Hospital.

    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 Cannock Chase Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to robustly monitor bottles of sevoflurane

    Wider context from the report

    “Notwithstanding an assurance that “the processes in place for safe supply, storage and use of Sevoflurane in the trust is in line with relevant sources of national guidance and best practice” the following remains a source of concern: That bottles of sevoflurane, whether unopened or partially used after theatre, does not appear to be robustly monitored to the degree that it was possible for a bottle of sevoflurane to be removed from Cannock Chase Hospital without this being flagged by the auditing system. That the trust was unable to confirm or refute that the bottle found at the deceased’s home address originated from Cannock Chase Hospital. ”
    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 Cannock Chase Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to confirm or refute the provenance of bottles of sevoflurane

    Wider context from the report

    “Notwithstanding an assurance that “the processes in place for safe supply, storage and use of Sevoflurane in the trust is in line with relevant sources of national guidance and best practice” the following remains a source of concern: That bottles of sevoflurane, whether unopened or partially used after theatre, does not appear to be robustly monitored to the degree that it was possible for a bottle of sevoflurane to be removed from Cannock Chase Hospital without this being flagged by the auditing system. That the trust was unable to confirm or refute that the bottle found at the deceased’s home address originated from Cannock Chase Hospital. ”
    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

Data last updated 7 September 2026