5 Feb 2025 Terence Grainger · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of an electronic system for recording patient observations View source
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
Terence Grainger · 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
Terence Grainger died at The Alexandra Hospital, Cheadle, from an acute left thoracic cavity haemorrhage following removal of a left-sided intercostal drain placed after coronary artery bypass graft surgery. The principal concern was that Circle Healthgroup Ltd had no plans to introduce electronic systems for recording patient observations, creating potential risks in recording timings, analysing trends and calculating NEWS 2 scores.
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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of an electronic system for recording patient observations
Wider context from the report “I am concerned that notwithstanding the limited steps Circle Healthgroup Ltd has taken towards introducing electronic patient records at its hospitals, the court heard evidence that no plans are currently in place to introduce an electronic system for recording patient observations .
I am concerned that an ongoing risk of future deaths arises from this position, in the view of the potential for such systems to accurately record timings of observations, facilitate trend analysis particularly in the context of a deteriorating patient, and reduce the potential for errors, either arising from incorrect / unclear manual recording of observations or miscalculating the NEWS 2 score.
” 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 Continue the Digital Transformation Programme to digitalise and harmonise patient administrative and clinical records.
Verbatim wording from the response “As you will no doubt be aware, introduction of a fully digitised and integrated health record has been a sector-wide ambition for many years. For this reason, and as shared during the coronial proceedings, CHG has already carried out significant work towards the digitalisation and harmonisation of patient administrative and clinical electronic records across CHG. This work is the fundamental aim of CHG’s Digital Transformation Programme, led by a dedicated team accountable to CHG’s board, which commenced prior to this recent case and is ongoing.” Source location Response from Circle Health Group Ltd
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 Introduce a full electronic patient record, including an expanded electronic patient observation system in ward settings.
Verbatim wording from the response “In the hope that it may assist with explaining CHG’s position on this matter, I have detailed below the current regulatory requirements and the progress CHG has made to date with regards to introducing its EPR. I must however start by confirming, as a matter of important clarification, that CHG has every intention of introducing a full EPR, including an expansion of an electronic patient observation system, such as those currently available in CHG’s critical care facilities, into ward-based settings. There are however a number of foundation steps that are planned ahead of this for reasons that I consider to be important, and which I have explained later in this letter.” Source location Response from Circle Health Group Ltd
Open published response
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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 Immediate implementation of ward-based electronic observations is limited by the complex, lengthy and safety-sensitive EPR transition process.
Verbatim wording from the response “In the hope that it may assist with explaining CHG’s position on this matter, I have detailed below the current regulatory requirements and the progress CHG has made to date with regards to introducing its EPR. I must however start by confirming, as a matter of important clarification, that CHG has every intention of introducing a full EPR, including an expansion of an electronic patient observation system, such as those currently available in CHG’s critical care facilities, into ward-based settings. There are however a number of foundation steps that are planned ahead of this for reasons that I consider to be important, and which I have explained later in this letter.” Source location Response from Circle Health Group Ltd
Open published response
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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 record-keeping requirements, controls and governance are considered sufficient pending implementation of the electronic patient record.
Verbatim wording from the response “Use of electronic observation systems in healthcare is not currently a regulatory requirement for Care Quality Commission (CQC) registered providers such as CHG. The accurate completion of contemporaneous records and the access to those by the treating team remains a key requirement of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, regulated by the CQC.” Source location Response from Circle Health Group Ltd
Open published response
16 May 2016 Mr Critall · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 23 Minimal respiratory consultant documentation View source Outdated chest drain management protocol lacking complication actions View source Use of 6 f gauge pigtail catheters for pleural effusions without supporting evidence View source Excessive patient caseloads and unclear experience among senior resident medical staff View source Failure to document clinical examination View source Failure to complete consent detailing chest drain complications View source Failure to request repeat inflammatory markers View source Poor communication of the post-procedure care plan to ward staff View source Failure to use a WHO checklist for radiological interventions View source Proactive chest drain insertion without objective clinical evidence View source Absence of a documented management plan View source Failure to use real-time ultrasound guidance for chest drain insertion View source Failure to establish clinical necessity for chest drain insertion View source Lack of Acute or Basic Life Support training for the radiologist View source Reliance on emergency paramedic attendance to provide hospital care before transfer View source Insufficient nursing competence in resuscitation and chest drain management View source Lack of independent radiological indications for chest drain insertion View source Chest drain insertion decisions influenced by the day of the week View source Failure to radiologically confirm the position of a non-draining chest drain View source Failure to record observations before and after chest drain procedures View source Admission of acutely unwell patients without onsite HDU/ITU facilities View source Absence of operational protocols for hospital emergency situations View source Absence of HDU or ITU capability for hospital emergency situations View source See 20 more concerns
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. 16
Action
Incorporate British Thoracic Society diagnostic guidance into the pathway for managing patients with pleural infection.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source
Action
Establish a local SOP requiring critically ill patients to move automatically to the theatre recovery area for comprehensive monitoring and anaesthetic support.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source
Action
Audit and reinforce complete consent documentation, including procedural risks, benefits, complications and radiological indication for chest-drain insertion.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source
Action
Require annual consultant reporting of completed mandatory training through the updated BMI practising privileges policy.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source
Action
Conduct monthly sample audits of consultant medical-record documentation and refer non-compliance for appropriate action.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source
Action
Review and update the Elective and Non-Elective Transfer Policy, agreeing emergency transfer processes with Royal Surrey County Hospital and making them available to relevant staff.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source
Action
Update the chest-drain care protocol to align with British Thoracic Society guidance.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source
Action
Develop a patient pathway linking ward and radiology teams, requiring pre- and post-procedure observations and clear handover communication.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source
Action
Reinforce contemporaneous consultant documentation of management plans, interventions and clinical examinations.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source
Action
Include chest-drain complication management procedures within the patient pathway for ward staff.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source
Action
Run regular unannounced resuscitation scenarios for staff and RMOs, identifying learning requirements for follow-up.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source
Action
Develop a consultant pathway presenting the patient’s clinical condition to support decisions about proceeding with interventional procedures.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source
Action
Require RMOs to meet hospital-specific experience and competency criteria, selecting familiar RMOs to improve continuity and consultant communication.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source
Action
Review and incorporate chest-drain insertion training and competencies for radiology and nursing staff into Acute Care Competencies.
Stated in progressThe respondent said that this action was in progress when they made their response on 16 May 2016. View source
Action
Promote British Thoracic Society guidance specifying larger 10–14 gauge tubes for pleural infection management.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source
Action
Train nursing staff and healthcare assistants in acute illness management and assess competencies for caring for deteriorating patients.
Stated completedThe respondent said that this action was complete when they made their response on 16 May 2016. View source See 13 more actions Respondent positions A position is what this recipient says about the concern when it does not describe a specific action. 8
Position
The proactive chest-drain approach was attributed only to the consultants concerned, with no evidence that other hospital consultants adopted it.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
Continuous hospital and radiology staffing, including an on-call radiographer, meant chest-drain decisions need not be influenced by the day of the week.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
The RMO met hospital-specific requirements, including GMC registration, life-support certification and relevant clinical experience.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
The hospital had an emergency transfer policy and facilities to stabilise critically ill patients before transfer.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
Nursing staff had required resuscitation training, with senior nurses generally holding advanced life-support certification.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
The radiology department already used the WHO procedural checklist, required comprehensive consent and audited compliance.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Consultants were required to maintain basic life-support training through practising-privileges and annual appraisal arrangements.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Admission was considered appropriate because the patient required only level 0 care and existing escalation arrangements supported deterioration management.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source See 7 more positions
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AI-generated summary
Mr Critall · 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 Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.
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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Minimal respiratory consultant documentation
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission . There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Outdated chest drain management protocol lacking complication actions
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose .
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Use of 6 f gauge pigtail catheters for pleural effusions without supporting evidence
Wider context from the report “8. The use of a 6 f gauge pig tail catheter in the management of pleural effusions with or without an empyema was against both national guidelines and expert evidence heard at inquest and was unsupported by either international research or any recent local audits undertaken to justify their use in preference for larger small bore chest drains .
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Excessive patient caseloads and unclear experience among senior resident medical staff
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72 . This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions, usually having to deal with malignant pleural effusions.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to document clinical examination
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete consent detailing chest drain complications
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications , radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to request repeat inflammatory markers
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Poor communication of the post-procedure care plan to ward staff
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to use a WHO checklist for radiological interventions
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist , no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Proactive chest drain insertion without objective clinical evidence
Wider context from the report “9. The court heard evidence there was a ‘local’ proactive approach for the insertion of chest drains based on no objective evidence other than a belief that the very smallest catheters were safer and more comfortable and reduced referral for surgical management of an empyema. This view was against expert evidence at inquest and concern was raised that this approach inevitably led to an excess of chest drains being inserted unnecessarily particularly when BTS guidelines were not being routinely applied and/or no evidence of a developing or actual empyema.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Absence of a documented management plan
Wider context from the report “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place , no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to use real-time ultrasound guidance for chest drain insertion
Wider context from the report “5. Real time ultrasound visualisation was not used to guide the chest drain insertion against ‘best practice’ . I was led to believe ‘best practice’ was not commonly practiced at the Royal Surrey County Hospital and in many other hospitals nationally. I also heard evidence real time ultrasound visualisation would have assisted the insertion as the effusion was small and lay in an awkward position close to tethering of the lung to the chest wall (which was not documented in the hospital notes or radiologist’s statement but was clearly present on ultrasound pictures examined by ████████ and acknowledged to be present by the radiologist who undertook the chest drain insertion in oral testimony).
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to establish clinical necessity for chest drain insertion
Wider context from the report “3. The insertion of a chest drain on the 4th July was not supported by British Thoracic Society (BTS) guidelines and was attempted on a background of an improving clinical picture without repeat of relevant investigations (e.g. inflammatory markers) or evidence of a developing or actual empyema or a further medical review, by either the radiologist or responsible clinician, to confirm its necessity .
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of Acute or Basic Life Support training for the radiologist
Wider context from the report “10. The radiologist did not have Acute or Basic Life Support training as would be expected for all clinical hospital staff as part of mandatory training for NHS appointments.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Reliance on emergency paramedic attendance to provide hospital care before transfer
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing competence in resuscitation and chest drain management
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions , usually having to deal with malignant pleural effusions.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of independent radiological indications for chest drain insertion
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant , a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Chest drain insertion decisions influenced by the day of the week
Wider context from the report “4. I heard evidence that the insertion of a chest drain may pre-empt difficulties that may arise if Mr Critall deteriorated over the approaching weekend. This was contrary to expert evidence that chest drain insertion should only be considered as a necessity and should not be influenced by the day of the week .
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to radiologically confirm the position of a non-draining chest drain
Wider context from the report “6. The position of the non-draining (second attempt) chest drain was not radiologically confirmed, against expected practice, particularly as it was not draining . I heard exert evidence that this resulted in a delay in the recognition and prompt management of the haemothorax which contributed to Mr Critall’s 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record observations before and after chest drain procedures
Wider context from the report “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Admission of acutely unwell patients without onsite HDU/ITU facilities
Wider context from the report “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration . The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions, usually having to deal with malignant pleural effusions.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Absence of operational protocols for hospital emergency situations
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Absence of HDU or ITU capability for hospital emergency situations
Wider context from the report “2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital.
” 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 Incorporate British Thoracic Society diagnostic guidance into the pathway for managing patients with pleural infection.
Verbatim wording from the response “5. Following the feedback from the coroner we have further strengthened the process for the management of patients with pleural infection, utilising the diagnostic algorithm for the management of such patients as described in the BTS guidelines 2010.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Establish a local SOP requiring critically ill patients to move automatically to the theatre recovery area for comprehensive monitoring and anaesthetic support.
Verbatim wording from the response “2. A local standard operating procedure (SOP) has been agreed at the hospital resuscitation committee to reinforce the management of a critically ill patient whereby a patient is automatically transferred to the recovery area within the hospital’s theatre complex to ensure access to comprehensive monitoring equipment and anaesthetic staff.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Audit and reinforce complete consent documentation, including procedural risks, benefits, complications and radiological indication for chest-drain insertion.
Verbatim wording from the response “In 2014 the WHO check list for procedures was introduced into the radiology department and is now every day practice and all consultants were aware of the requirement to undertake a comprehensive consent detailing risks and benefits of the procedure. Following the incident the consultant body were reminded of the necessity to ensure that documentation is complete detailing possible complications on each consent form. This process is subject to audit which confirms compliance with this standard.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Require annual consultant reporting of completed mandatory training through the updated BMI practising privileges policy.
Verbatim wording from the response “In 2014 the BMI Practicing Privileges policy required confirmation of a completed appraisal whereby a consultant’s Responsible Officer /Clinical Director would confirm that all requirements for the appraisal were met. Since that time an updated practicing privileges policy has been introduced across all BMI hospitals which includes a requirement that details of completed mandatory training are provided by all consultants on an annual basis.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 monthly sample audits of consultant medical-record documentation and refer non-compliance for appropriate action.
Verbatim wording from the response “2. Consultant input into the medical record is subject to a monthly audit on a sample basis and audit results indicate significant improvement.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Review and update the Elective and Non-Elective Transfer Policy, agreeing emergency transfer processes with Royal Surrey County Hospital and making them available to relevant staff.
Verbatim wording from the response “1. The hospital’s Elective and Non-Elective Transfer Policy, has been reviewed and updated to reinforce the registered level of care provided by the hospital. The process for transfer in an emergency situation was agreed with the Medical Director at the Royal Surrey County Hospital NHS Trust and incorporated into the policy. The Policy is available for RMO and senior nursing staff within the RMO induction and bleep holder file.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Update the chest-drain care protocol to align with British Thoracic Society guidance.
Verbatim wording from the response “4. The protocol for the care of patients with a chest drain has been updated to align with British Thoracic Society (BTS) guidelines. Training and competencies for all radiology and nursing staff on the understanding of chest drain insertion is currently under review by BMI to be incorporated in the Acute Care Competencies.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 a patient pathway linking ward and radiology teams, requiring pre- and post-procedure observations and clear handover communication.
Verbatim wording from the response “2. A patient pathway has been developed for patients undertaking this type of procedure to ensure improved communication between staff on the ward and in radiology. The pathway ensures base line observations are recorded prior to and following the procedure and requires clear communication on handover.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 contemporaneous consultant documentation of management plans, interventions and clinical examinations.
Verbatim wording from the response “1. There have been a number of initiatives across the hospital in the last 2 years to reinforce the standard and ensure that all consultants are aware of the requirement to make contemporaneous notes regarding their patients.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Include chest-drain complication management procedures within the patient pathway for ward staff.
Verbatim wording from the response “3. The pathway includes the protocol for the management of chest drains on the ward which addresses actions to take if complications arise.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Run regular unannounced resuscitation scenarios for staff and RMOs, identifying learning requirements for follow-up.
Verbatim wording from the response “2. All staff and RMO’s are involved with regular unannounced resuscitation scenarios run at the hospital by an externally appointed resuscitation training company engaged to teach resuscitation skills to all staff. Any learning requirements are identified to staff and to the RMOs and their agency.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 a consultant pathway presenting the patient’s clinical condition to support decisions about proceeding with interventional procedures.
Verbatim wording from the response “3. We have developed a pathway which provides consultants with a clear picture of the patient’s clinical condition which will support any decision regarding the progression to an interventional procedure.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Require RMOs to meet hospital-specific experience and competency criteria, selecting familiar RMOs to improve continuity and consultant communication.
Verbatim wording from the response “1. Any RMO’s offered to the hospital are required to meet specific criteria regarding previous experience and competency and a number of RMOs have been specifically selected who are familiar with the hospital, the consultants and nursing staff with the aim of improving continuity of care and communication with consultants.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Review and incorporate chest-drain insertion training and competencies for radiology and nursing staff into Acute Care Competencies.
Verbatim wording from the response “4. The protocol for the care of patients with a chest drain has been updated to align with British Thoracic Society (BTS) guidelines. Training and competencies for all radiology and nursing staff on the understanding of chest drain insertion is currently under review by BMI to be incorporated in the Acute Care Competencies.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Promote British Thoracic Society guidance specifying larger 10–14 gauge tubes for pleural infection management.
Verbatim wording from the response “1. As discussed previously in the response to Concern 6, BTS guidance for the management of patients with pleural infection is promoted which includes reference to the use of a larger bore tube size 10 – 14.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Train nursing staff and healthcare assistants in acute illness management and assess competencies for caring for deteriorating patients.
Verbatim wording from the response “3. All nursing staff and Health Care Assistants have attended AIMS (Acute Illness Management training) and completed competencies in the care of the deteriorating patient.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
Open published response
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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 proactive chest-drain approach was attributed only to the consultants concerned, with no evidence that other hospital consultants adopted it.
Verbatim wording from the response “The ‘local’ proactive approach described was specific to the consultants concerned based on their practice and experience. There is no evidence that any other consultants at the hospital adopted such an approach.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
Open published response
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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 Continuous hospital and radiology staffing, including an on-call radiographer, meant chest-drain decisions need not be influenced by the day of the week.
Verbatim wording from the response “The decision to insert a chest drain should not be influenced by the day of the week. The hospital is open and staffed 24 hours a day, 7 days a week as is the Radiology department. An on call radiographer is provided to enable procedures to be carried out whenever required. Consultants are not expected to make such clinical decisions based on the day of the week.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
Open published response
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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 RMO met hospital-specific requirements, including GMC registration, life-support certification and relevant clinical experience.
Verbatim wording from the response “Resident Medical Officer (RMO) - The role of the RMO is to respond to requests from consultants and nursing staff in matters which require medical input and involves the assessment of surgical and medical patients who deviate from the treatment pathway, and deteriorating patients. RMO’s are provided to the hospital by an agency and are provided on the basis that they are able to work within the clinical requirements specific to the hospital, including GMC registration, a current Advanced Life Support certificate and European Paediatric Life Support certificate and experience in cancer care. This was the case for the RMO on duty that day.
At the time of Mr Critall’s admission, the hospital was registered for 72 beds.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
Open published response
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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 hospital had an emergency transfer policy and facilities to stabilise critically ill patients before transfer.
Verbatim wording from the response “The hospital has an Elective and Non-Elective Transfer Policy in place which sets out the requirements for transfer of patients in emergency situations. The policy acknowledges that clinical deterioration can occur at any stage of a patient’s pathway. The National Early Warning Score (NEWS) is a tool to support staff to recognise deterioration at an early stage and escalate for medical assessment by the RMO. If following assessment it is deemed necessary, the patient’s consultant or other relevant professional, e.g. consultant anaesthetist should be contacted for advice or asked to attend.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Nursing staff had required resuscitation training, with senior nurses generally holding advanced life-support certification.
Verbatim wording from the response “Nursing staff - All hospital staff receive either advanced life support (ALS); basic life support (BLS) or immediate life support (ILS) resuscitation council accredited training. All nursing staff are ILS trained as a minimum requirement and the current senior nursing team are ALS trained with the exception of 1 member of the team. The requirement is for renewal every 4 years. In the intervening years between formal ALS training all ALS qualified staff attend an ALS refresher (previously this was an ILS refresher).” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 radiology department already used the WHO procedural checklist, required comprehensive consent and audited compliance.
Verbatim wording from the response “In 2014 the WHO check list for procedures was introduced into the radiology department and is now every day practice and all consultants were aware of the requirement to undertake a comprehensive consent detailing risks and benefits of the procedure. Following the incident the consultant body were reminded of the necessity to ensure that documentation is complete detailing possible complications on each consent form. This process is subject to audit which confirms compliance with this standard.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
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 Consultants were required to maintain basic life-support training through practising-privileges and annual appraisal arrangements.
Verbatim wording from the response “All consultants are required to have basic life support training as a minimum. As part of the practising privileges that are granted to consultants to allow them to practice at the hospital, annual practice appraisals are conducted, part of which is a requirement for a consultant’s responsible officer to confirm that basic life support training has been completed.” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
Open published response
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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 Admission was considered appropriate because the patient required only level 0 care and existing escalation arrangements supported deterioration management.
Verbatim wording from the response “hospital’s resident medical officer (RMO) as required. Following assessment by the RMO if necessary, the patient’s consultant or other relevant professional, e.g. consultant anaesthetist would be contacted for advice or asked to attend. On admission, Mr Critall’s condition was assessed to be level 0, an appropriate admission to the hospital” Source location 2016-0187-Response-by-Mount-Alvernia-Hospital
Open published response
Concerns raised 4 Failure of nursing staff to raise known risk factors with consultants View source Inadequate staff training View source Corporate pharmacy guideline documentation contradicting NICE guidance View source Failure to comply with the Duty of Candour View source See 1 more concern
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
Sally Ann Tooze Froggatt · 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
Sally Ann Tooze Froggatt died on 6 April 2015 at Royal Lancaster Infirmary following multiple missed opportunities to treat her high risk of venous thromboembolism. Concerns included failures in the Duty of Candour, inadequate staff training, potentially contradictory pharmacy guidance, and failure to raise known risk factors with consultants.
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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing staff to raise known risk factors with consultants
Wider context from the report “4. failure of BMI nursing staff to raise known risk factors with consultants
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training
Wider context from the report “2. inadequate training of 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Corporate pharmacy guideline documentation contradicting NICE guidance
Wider context from the report “3. corporate pharmacy guideline documentation that appears to contradict the NICE guidance referred to in other corporate literature
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to comply with the Duty of Candour
Wider context from the report “1. a failure to comply with the Duty of Candour
” Open source report
8 Jul 2015 Amanda Jane Ellams · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to maintain complete and accessible medical and nursing records View source Failure of the out-of-hours District Nursing telephone system to answer calls View source Failure to ensure safe oxygen saturation levels before discharge View source Failure to adequately record and monitor blood oxygen levels View source Failure to prevent unsafe disconnection of oxygen supply and departure from the ward View source See 2 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
Amanda Jane Ellams · 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
Amanda Jane Ellams died approximately four days after surgery to repair an incisional hernia in February 2015. The concerns included inadequate medical and nursing record-keeping, incomplete pre-operative medical information, discharge despite low oxygen saturations and inadequate oxygen monitoring, and three unanswered calls to the out-of-hours District Nursing telephone service during the night of her death.
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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain complete and accessible medical and nursing records
Wider context from the report “1. During the course of the inquest it was apparent that the standard of note keeping at the Alexandra Hospital (both medical and nursing) was well below that which would be generally regarded as satisfactory . There was even one attendance on the patient by the consultant surgeon in February (according to the surgeon’s evidence to me) for which there was no written record whatsoever . The surgeon conceded that he did not have a full medical history available to him pre-operatively and he was not aware of all the prescribed drugs which she was taking . (BMI Healthcare)
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the out-of-hours District Nursing telephone system to answer calls
Wider context from the report “3. The out-of-hours telephone system for the District Nursing team in Tameside area was operated by Good HealthCare (which also provides the out-of-hours GP service in that area). It was apparent that during the night of her death, Mrs Ellams had made three separate calls to the telephone number she had been given to contact the District Nurses and none of those calls was answered . The duration of the unanswered calls was 2 minutes, 1 minute 50 seconds and 1 minute 14 seconds respectively. In giving his evidence, the Chief Executive of GTD conceded that “it is a flawed system” . (GTD Healthcare)
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure safe oxygen saturation levels before discharge
Wider context from the report “2. The Alexandra Hospital Staff Nurse conceded that Mrs Ellams was discharged from hospital even though it is now clear that her oxygen saturations were still too low for such discharge to take place . There was what appeared to be a very lax attitude to recording and monitoring the Blood/Oxygen levels and the patient was allowed to disconnect her oxygen supply and walk out of the ward to go for a cigarette. (BMI Healthcare)
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately record and monitor blood oxygen levels
Wider context from the report “2. The Alexandra Hospital Staff Nurse conceded that Mrs Ellams was discharged from hospital even though it is now clear that her oxygen saturations were still too low for such discharge to take place. There was what appeared to be a very lax attitude to recording and monitoring the Blood/Oxygen levels and the patient was allowed to disconnect her oxygen supply and walk out of the ward to go for a cigarette. (BMI Healthcare)
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent unsafe disconnection of oxygen supply and departure from the ward
Wider context from the report “2. The Alexandra Hospital Staff Nurse conceded that Mrs Ellams was discharged from hospital even though it is now clear that her oxygen saturations were still too low for such discharge to take place. There was what appeared to be a very lax attitude to recording and monitoring the Blood/Oxygen levels and the patient was allowed to disconnect her oxygen supply and walk out of the ward to go for a cigarette . (BMI Healthcare)
” Open source report
Concerns raised 5 Lack of clear authorisation for postoperative physiotherapy View source Unsafe physiotherapy involving forceful blowing after surgery View source Failure to monitor and respond promptly to postoperative neck and facial swelling View source Unavailability of a functioning fibre-optic endoscopic light source during critical surgery View source Failure to maintain appropriate communication and privacy around critical incidents View source See 2 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
Barbara Joan Harrison · 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 Joan Harrison was admitted on 5 February 2015 for surgery after worsening swallowing and regurgitation symptoms, and subsequently developed significant surgical emphysema and undetected mediastinitis. Concerns included potentially harmful postoperative physiotherapy, failed attempts to site an endotracheal tube due in part to unavailable fibre-optic equipment, inadequate lighting during critical surgery, distress caused to her family, and delayed recognition of swelling around her neck and face.
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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of clear authorisation for postoperative physiotherapy
Wider context from the report “1. After the first surgery at the Alexandra Hospital she was subjected to physiotherapy involving blowing hard into a peak flow meter. This undoubtedly either caused or contributed to the breakdown of the tissues around the operative site. It is unclear as to who ordered this physiotherapy , as ████████ the surgeon and ████████ the anaesthetist both indicated that they did not do so and would not have done so .
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Unsafe physiotherapy involving forceful blowing after surgery
Wider context from the report “1. After the first surgery at the Alexandra Hospital she was subjected to physiotherapy involving blowing hard into a peak flow meter . This undoubtedly either caused or contributed to the breakdown of the tissues around the operative site . It is unclear as to who ordered this physiotherapy, as ████████ the surgeon and ████████ the anaesthetist both indicated that they did not do so and would not have done so.
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor and respond promptly to postoperative neck and facial swelling
Wider context from the report “5. After the first surgery had taken place, the family noticed there was a rapid and very obvious swelling around the neck and face of Mrs Harrison . Why did the nurses not note this and act upon it earlier?
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a functioning fibre-optic endoscopic light source during critical surgery
Wider context from the report “2. During surgery to repair the oesophageal pouch, there were a total of three attempts to site an endo-tracheal tube and on each occasion it failed. Part of the reason for this was that it was found that the batteries for the fibre optic tube were flat and inoperable. No replacement could be found.
3. ████████ averred that “we never got a light source at all ” during the operation. This is an unacceptable situation during a critical operative procedure. He then went on to say “ The need for an endoscope was critical and this is now a panic situation with the possibility of something going catastrophically wrong”
” 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 Circle Health Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain appropriate communication and privacy around critical incidents
Wider context from the report “4. Whilst the patient was in theatre for the emergency procedure, her family were advised to wait in the restaurant or reception areas of the hospital . As they were waiting, they heard one of the porters shout out “we have got a cardiac arrest in theatre.” This caused them extreme distress and alarm.”
” Open source report
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Addressed to “BMI HEALTHCARE LIMITED”, a former name of Circle Health Group Limited.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations