Recipient

Consultant orthopaedic surgeon

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First report 10 May 2021•Latest report 10 May 2021

Recipient record

Reports, concerns and published responses

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
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Consultant orthopaedic surgeon linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Brighton and Hove

    AI-generated summary

    Mr. John Charles LOTT · 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

    John Lott underwent surgery to form a defunctioning ileostomy and subsequently became seriously unwell, including inadequately treated hypoglycaemia, myocardial ischaemia and infarction. He died on 8 November 2020 after two occasions when transfer from the private hospital to an NHS hospital with appropriate critical care facilities was considered necessary but did not occur. Concerns included missed transfer opportunities, inadequate management of hypoglycaemia, and a lack of contact with the on-call anaesthetist when the consultant was unavailable.

    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 Consultant orthopaedic surgeon; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to sufficiently highlight the transfer policy to nursing staff and Resident Medical Officers

    Wider context from the report

    “(3) When ████████ the Consultant “in charge” of Mr. Lott was not immediately available no one appears to have been contacted the on call anaesthetist for input and support. Why not? Is the transfer policy sufficiently highlighted for nursing staff and Resident Medical Officers? ”
    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 Consultant orthopaedic surgeon; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to manage hypoglycaemia

    Wider context from the report

    “(1) On 27ᵗʰ October 2020, Mr. Lott’s NEWS 2 scores were so high as to require transfer to a hospital with appropriate critical care facilities not available at the Brighton Nuffield. (2) On the 29ᵗʰ October Mr. Lott’s hypoglycaemia was not being managed. He should have been transferred. ”
    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 Consultant orthopaedic surgeon; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to contact the on-call anaesthetist for input and support when the consultant is unavailable

    Wider context from the report

    “(3) When ████████ the Consultant “in charge” of Mr. Lott was not immediately available no one appears to have been contacted the on call anaesthetist for input and support. Why not? Is the transfer policy sufficiently highlighted for nursing staff and Resident Medical Officers? ”
    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 Consultant orthopaedic surgeon; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to transfer patients requiring higher-level care to appropriate critical care facilities

    Wider context from the report

    “(1) On 27ᵗʰ October 2020, Mr. Lott’s NEWS 2 scores were so high as to require transfer to a hospital with appropriate critical care facilities not available at the Brighton Nuffield. (2) On the 29ᵗʰ October Mr. Lott’s hypoglycaemia was not being managed. He should have been transferred. ”
    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

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

How actions were described at the time

This respondent
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