Recipient

Chesterfield Royal Hospital

First report 9 Jun 2014•Latest report 4 Feb 2020

Recipient record

Reports, concerns and published responses

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

Reports: 3
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

4 Feb2020
Derby and Derbyshire
Concerns raised1
1. Unavailability of urgent transfers for acutely ill patients due to resourcing issues
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

Mr Gordon Gillott · 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

Mr Gordon Gillott presented with a ruptured abdominal aneurysm, underwent surgery, and later died from sepsis secondary to a bowel perforation. The principal concern was a substantial ambulance delay in transferring him, caused by resourcing issues, creating a risk of future deaths among acutely ill patients requiring urgent transfers.

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 Chesterfield Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of urgent transfers for acutely ill patients due to resourcing issues
Wider context from the report
“1. Whilst this delay did not affect Mr Gillott, were this to happen again in the future, there is a risk of future death if urgent transfers are not available to acutely ill patients due to resourcing issues. ”
Open source report
21 Sep2017
Derby and Derbyshire
Concerns raised1
1. Failure to communicate confirmed fractures and necessary care measures to relevant care providers
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

Barbara Christine Sturgess · 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

Barbara Christine Sturgess, who had advanced dementia and was at high risk of falls, sustained a cervical spinal fracture in a fall at her nursing home on 20 May 2017 and died of bronchopneumonia on 8 June 2017. The hospital did not initially inform the nursing home or GP practice of the fracture or necessary care measures; although this was not evidenced to have contributed to her death, it had the potential to adversely affect her wellbeing and could contribute to death in similar cases.

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 Chesterfield Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate confirmed fractures and necessary care measures to relevant care providers
Wider context from the report
“The Chesterfield Royal Hospital did not inform the nursing home or the GP practice that Barbara Christine Sturgess had sustained a cervical spinal fracture nor of any necessary measures in her care and treatment. Her daughter attended a fracture clinic appointment with her on 24 May 2017 where a Doctor told the daughter that a fracture had been sustained and that care should be exercised in her management on account of the fracture. It was only on 26 May 2017, as a result of enquiries by the nursing home, that formal confirmation of the fracture was provided by the hospital. Although there was no evidence that the failure of the hospital to properly confirm and advise on the fracture was a factor in Barbara Christine Sturgess’s death this did have the potential to adversely affect her wellbeing. Very importantly if there were to be further similar failings in communication it could be that for some patients this could be a contributory factor in death. ”
Open source report
9 Jun2014
Derby and Derbyshire
Concerns raised3
1. Lack of formal assessment of the patient’s abilities, home environment and carer’s ability to provide care
2. Lack of a formal policy or procedure for risk assessing early-hours discharge of frail elderly patients to home
3. Failure to undertake post-discharge planning and assessment of follow-up care needs
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

William Leonard Beckwith · 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

William Leonard Beckwith sustained a cervical spine fracture after a fall at home, was discharged from hospital without the fracture being diagnosed, and died on 11 October 2013 after readmission with acute stridor and subsequent deterioration. The principal concern was that, despite his age and history of falls, he was discharged home in the early hours without formal assessment of his abilities, his home environment, or his wife’s ability to care for him, and without post-discharge planning or needs assessment.

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 Chesterfield Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of formal assessment of the patient’s abilities, home environment and carer’s ability to provide care
Wider context from the report
“A 91 year old patient, with a history of falls and who had attended A&E due to a fall was discharged home at 04:17 hours in the early morning to his elderly wife. There was no formal assessment as to his abilities, the home environment or his wife’s abilities to look after him. No consideration was given to post discharge planning or assessment of needs such as district nurse or social care follow up. The Department, at that time, did not have in place any formal policy or procedure for risk assessing the safety of discharging a frail, elderly patient to home in the early hours of the morning. ”
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 Chesterfield Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of a formal policy or procedure for risk assessing early-hours discharge of frail elderly patients to home
Wider context from the report
“A 91 year old patient, with a history of falls and who had attended A&E due to a fall was discharged home at 04:17 hours in the early morning to his elderly wife. There was no formal assessment as to his abilities, the home environment or his wife’s abilities to look after him. No consideration was given to post discharge planning or assessment of needs such as district nurse or social care follow up. The Department, at that time, did not have in place any formal policy or procedure for risk assessing the safety of discharging a frail, elderly patient to home in the early hours of the morning. ”
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 Chesterfield Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake post-discharge planning and assessment of follow-up care needs
Wider context from the report
“A 91 year old patient, with a history of falls and who had attended A&E due to a fall was discharged home at 04:17 hours in the early morning to his elderly wife. There was no formal assessment as to his abilities, the home environment or his wife’s abilities to look after him. No consideration was given to post discharge planning or assessment of needs such as district nurse or social care follow up. The Department, at that time, did not have in place any formal policy or procedure for risk assessing the safety of discharging a frail, elderly patient to home in the early hours of the morning. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised1

Unavailability of urgent transfers for acutely ill patients due to resourcing issues

Concerns raised1

Failure to communicate confirmed fractures and necessary care measures to relevant care providers

Concerns raised3

Lack of formal assessment of the patient’s abilities, home environment and carer’s ability to provide care

Lack of a formal policy or procedure for risk assessing early-hours discharge of frail elderly patients to home

Failure to undertake post-discharge planning and assessment of follow-up care needs