Concerns raised 1 Failure to ensure patients can consistently complete a flight of stairs without assistance before discharge 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
Susan Elizabeth SAMSON · 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
Susan Elizabeth SAMSON died on 7 May 2025 after falling down the stairs at her home, following discharge from a rehabilitation placement. The principal concern was that patients may be discharged before they can consistently use stairs without assistance, potentially resulting in a death.
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× 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure patients can consistently complete a flight of stairs without assistance before discharge
Wider context from the report “The Occupational Therapist involved in the deceased's discharge on 1 May 2025 gave evidence that for someone to be assessed as safe to use the stairs on their own, it was not sufficient for them to have managed to complete a set of stairs without assistance on one occasion; it was necessary for the person to demonstrate that they could consistently complete the stairs without assistance . The Occupational Therapist stated that the two successful attempts in the Care Home seemed to be enough to achieve consistency and indicated that if similar circumstances arose today the patient would still be discharged home at the end of the six-week rehabilitation period.
I found as a fact that prior to the deceased's discharge on 1 May 2025 the deceased had not demonstrated that she was able to consistently complete a flight of stairs without assistance.
I am concerned by the evidence that if similar circumstances arose today the patient would still be discharged. I am concerned that there may be occasions in the future that patients will be discharged before they are able to consistently complete a flight of stairs and that, as a result, a death may occur.
” 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 Deliver SOAP note training to Community Physiotherapy, Occupational Therapy and Assistant staff within six weeks, and remaining Physiotherapy and Occupational Therapy staff within four months.
Verbatim wording from the response “The documentation relating to the stair attempts undertaken prior to discharge from the intermediate care setting does not clearly confirm that the patient completed the stairs without assistance and lacks sufficient objective assessment and clinical analysis. The Trust requires the use of the recognised SOAP note structure (Subjective, Objective, Assessment and Plan) when recording assessments, which was completed, however the use of the term supervision should have been more clearly defined.” Source location Response from County Durham and Darlington NHS Foundation Trust
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 Repeating stair assessments is not always necessary where a patient previously completed one safely and has no additional risk factors.
Verbatim wording from the response “It is not always necessary to repeat a stair assessment. The decision should be guided by the clinician’s professional judgement and the patient’s individual risk profile. If a patient has previously completed a stair assessment safely and no additional risk factors are present, repetition is unlikely to be required. However, for individuals with identified risk such as a history of falls, reduced strength or balance, or frailty, repeating the assessment can provide valuable reassurance by demonstrating consistency and safety over time.” Source location Response from County Durham and Darlington NHS Foundation Trust
Open published response
Concerns raised 1 Failure to prevent erroneous reductions in the frequency of care rounds View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Victor Jackson HUTCHENS · 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
Victor Jackson HUTCHENS died at Darlington Memorial Hospital on 27 February 2025 as a result of an accidental fall causing a head injury. A week before his death, care rounds were mistakenly reduced from hourly to four-hourly, raising concern that the error could recur and cause or contribute to a future death, although the inquest found it could not be said on a balance of probabilities that the error contributed to his death.
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× 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent erroneous reductions in the frequency of care rounds
Wider context from the report “On 20 February 2025, a week before the deceased's death, the frequency of care rounds was reduced, in error, from hourly to four-hourly . The member of staff responsible for the error is unaware of how the error occurred . That being the case, there is a concern that the error could occur again and could cause or contribute to a future death.
” 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 Deliver education to the ward team distinguishing care rounding from observation frequency and reinforcing required clinical justification and oversight.
Verbatim wording from the response “In response, we have undertaken a comprehensive education programme with the ward team to clarify the distinct purposes of care rounding and observation frequency, and to reinforce that neither should be reduced without appropriate clinical justification and oversight.” Source location Response from County Durham and Darlington NHS Foundation Trust
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 organisation-wide audits to identify incorrect care-rounding practices and regularly monitor that correct practices remain embedded.
Verbatim wording from the response “We have also conducted an organisation-wide audit to ensure this issue is not occurring elsewhere. Where similar practices have been identified, remedial education has been undertaken with the relevant teams. We continue to audit regularly to ensure that correct practices are maintained and embedded across all areas.” Source location Response from County Durham and Darlington NHS Foundation Trust
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 Provide remedial education to teams where similar care-rounding practices are identified.
Verbatim wording from the response “We have also conducted an organisation-wide audit to ensure this issue is not occurring elsewhere. Where similar practices have been identified, remedial education has been undertaken with the relevant teams. We continue to audit regularly to ensure that correct practices are maintained and embedded across all areas.” Source location Response from County Durham and Darlington NHS Foundation Trust
Open published response
Concerns raised 6 Failure to establish and communicate accurate baseline presentation and inpatient mobility information for discharge care planning View source Inadequate quality and accuracy of outsourced out-of-hours radiological reporting View source Unavailability of reporting radiologists for discussion of radiological findings View source Failure to communicate diagnosis, treatment options, rationale and discharge plans with family representatives View source Failure to maintain accurate information about baseline presentation for discharge planning and risk assessment View source Failure to arrange follow-up appointments after discharge View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Esther Jane Lancaster Byrne · 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
Esther Jane Lancaster Byrne, who had vascular dementia and was extremely frail, died at her care home on 18 December 2024 after deterioration following a fall, a neck of femur fracture, surgery and discharge back to the care home. Concerns included poor communication with the family and power-of-attorney holder, misunderstandings about her baseline and mobility affecting discharge planning, failure to arrange follow-up, and doubts about the quality and accuracy of outsourced radiological reporting.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish and communicate accurate baseline presentation and inpatient mobility information for discharge care planning
Wider context from the report “2. There were numerous discrepancies in the evidence demonstrating a misunderstanding by various medical staff as to the deceased's baseline presentation, and the extent to which she had or had not mobilised whilst an inpatient which were pertinent to care planning upon discharge and to any handling required to be risk managed by the care home.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate quality and accuracy of outsourced out-of-hours radiological reporting
Wider context from the report “4. The treating consultant physician expressed considerable doubt as to the quality and accuracy of radiological reporting provided by the outsourced out of hours service (which is understood to be outside the UK) and accepted that this issue, amongst others, contributed to his doubt that the deceased had sustained a fracture. The Inquest heard that there was no ability to discuss the findings with the reporting 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of reporting radiologists for discussion of radiological findings
Wider context from the report “4. The treating consultant physician expressed considerable doubt as to the quality and accuracy of radiological reporting provided by the outsourced out of hours service (which is understood to be outside the UK) and accepted that this issue, amongst others, contributed to his doubt that the deceased had sustained a fracture. The Inquest heard that there was no ability to discuss the findings with the reporting 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate diagnosis, treatment options, rationale and discharge plans with family representatives
Wider context from the report “1. Poor communication and liaison with family generally, and in particular with a family member who held a health and welfare power of attorney , led to important information being incorrect, including about such issues as the deceased's baseline presentation which was pertinent to safe discharge planning and risk assessment. It was accepted that there was no communication with the family member who held power of attorney regarding diagnosis and treatment options, the rationale for these, or the discharge plan .
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate information about baseline presentation for discharge planning and risk assessment
Wider context from the report “1. Poor communication and liaison with family generally, and in particular with a family member who held a health and welfare power of attorney, led to important information being incorrect, including about such issues as the deceased's baseline presentation which was pertinent to safe discharge planning and risk assessment. It was accepted that there was no communication with the family member who held power of attorney regarding diagnosis and treatment options, the rationale for these, or the discharge plan.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange follow-up appointments after discharge
Wider context from the report “3. It was accepted that a follow up appointment should have been arranged for the deceased after discharge and there was no explanation for why this was not arranged .
” 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 Ensure physiotherapists attend orthopaedic ward rounds and access electronic clinical records for mobility-related decision-making.
Verbatim wording from the response “Although there was a plan for the patient to be discharged back to her care home, the physiotherapists were planning to complete further mobility assessments including considering using a hoist for transfers. Unfortunately this assessment did not take place prior to Ms Byrne’s discharge back to the care home. The patient had not returned to her baseline level of mobility and therefore a further discussion with the family care home should have taken place to ensure the care home could meet Ms Byrne’s care needs.
As a result of this the ward has made adjustments to ensure the physiotherapy team attend orthopaedic ward rounds and have access to electronic clinical records to ensure they are involved in decision making and contribute to discussion regarding the mobility status of patients.” Source location Response from County Durham and Darlington NHS Foundation Trust
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 regular ward audits to monitor compliance with the follow-up appointment process.
Verbatim wording from the response “The accountable doctor, ████████ accepts that the lack of a scheduled follow up appointment was an error on his part. A discharge process is in place to include scheduling a follow up appointment for every patient (if required) and confirmation is documented in the patient records. To ensure compliance with this process regular ward audits will be completed to provide assurance.” Source location Response from County Durham and Darlington NHS Foundation Trust
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 Allocate a multidisciplinary team member on ward rounds to update families about all aspects of patient care.
Verbatim wording from the response “On review of the care the ward team were unaware that a family member had Power of Attorney for health and welfare. However the trust acknowledges that communication with the family was poor. On review of this issue the Orthopaedic team will ensure that a member of multi-disciplinary team is allocated on the ward round to update the family regarding all issues of the patients care. To provide assurance to the organisation of meeting this standard, regular audits will be completed by the relevant ward manager by a retrospective clinical record review.” Source location Response from County Durham and Darlington NHS Foundation Trust
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 Record patients’ mobility status in discharge letters through physiotherapy and occupational therapy input.
Verbatim wording from the response “As a further action physio and occupational therapist will input to patient’s discharge letter to record patients mobility status.” Source location Response from County Durham and Darlington NHS Foundation Trust
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 regular retrospective clinical-record audits to monitor compliance with family communication standards.
Verbatim wording from the response “On review of the care the ward team were unaware that a family member had Power of Attorney for health and welfare. However the trust acknowledges that communication with the family was poor. On review of this issue the Orthopaedic team will ensure that a member of multi-disciplinary team is allocated on the ward round to update the family regarding all issues of the patients care. To provide assurance to the organisation of meeting this standard, regular audits will be completed by the relevant ward manager by a retrospective clinical record review.” Source location Response from County Durham and Darlington NHS Foundation Trust
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 Circulate and share a flow chart setting out escalation contacts for difficult out-of-hours radiologist communication.
Verbatim wording from the response “The Trust acknowledges that there may be occasions when contacting the out-of-hours radiologist proves challenging. In such cases, the duty radiologist should be contacted as the next point of escalation.
To ensure all clinical teams are fully informed of this protocol, a flow chart detailing the contact process has been circulated. This has also been shared directly with the orthopaedic consultants to support consistent application across relevant departments.” Source location Response from County Durham and Darlington NHS Foundation Trust
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 Use a discharge process requiring follow-up appointments when needed and documenting confirmation in patient records.
Verbatim wording from the response “The accountable doctor, ████████ accepts that the lack of a scheduled follow up appointment was an error on his part. A discharge process is in place to include scheduling a follow up appointment for every patient (if required) and confirmation is documented in the patient records. To ensure compliance with this process regular ward audits will be completed to provide assurance.” Source location Response from County Durham and Darlington NHS Foundation Trust
Open published response
Concerns raised 6 Lack of clear and timely internal and external fall reporting View source Failure to clearly document medical advice obtained after resident falls View source Failure to promptly re-evaluate and amend care plans after significant events View source Failure to provide effective, individually tailored monitoring measures for residents at high risk of falls View source Failure to obtain timely medical advice after a resident fall View source Failure to maintain accessible and retained resident records View source See 3 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.
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AI-generated summary
Sylvia Margaret Louisa SAVAGE · 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
Sylvia Margaret Louisa Savage died on 25 April 2023 at the University Hospital of North Durham from bronchopneumonia, following a fall from her bed at Redwell Hills Care Home on 18 March 2023 and subsequent injuries and decline in health. The concerns included unclear fall-reporting arrangements, ineffective monitoring of her mobilisation, inadequate post-fall medical assessment, missing or insufficient care records, and failure to promptly reassess her care plan after falls.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and timely internal and external fall reporting
Wider context from the report “1. There was I heard no clear definition of when to report falls externally & internally - this to me is perhaps the reason why the fall Mrs Savage suffered on 1/2/23 was not recorded internally, all be it CQC were notified on this occasion. The fall on 18/3/23 was not reported to CQC and whilst I understand staff at the care home did not know the outcome of Mrs Savage's treatment in hospital - she left the home by ambulance and did not return. This seems an occurrence worthy of reporting – It strikes me some clearer reporting structure is necessary - timely and accurate reporting both internally and to regulators allows for those concerned to assess the care home and decide on whether there are risks/issues that need addressing and protect residents. I would suggest over reporting is preferable to under reporting.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly document medical advice obtained after resident falls
Wider context from the report “3. Mrs Savage's fall in February 2023 was it appears reported to her GP by her daughter and that led to a nurse attending the home to examine her. Staff at the home do not appear to have done so themselves. It is of concern that after a fall the staff within the home should have a mechanism to ensure medical advice is obtained in a timely fashion and that it is documented clearly and not be reliant on family members summoning help for residents themselves when they have become aware of an incident.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly re-evaluate and amend care plans after significant events
Wider context from the report “5. The evidence I have heard is after Mrs Savage's fall on 1/2/23 and when it became clear the sensor mat was not working as intended - this should have prompted staff to return to the care plans and re-evaluate them - it did not . Indeed one care home witness stated as Mrs Savage had not had 3 falls in 3 months no change to her plan was needed. Given the second fall Mrs Savage had some weeks later gave her injuries that led to her death this approach appears flawed. Whilst I acknowledge work is ongoing in this area it appears that prompt re-evaluation of the care plans after events such as a fall are necessary to prevent injury and death - I would ask for some reassurance that significant events are captured by staff and in turn their significance is carefully considered and if necessary changes made to care .
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective, individually tailored monitoring measures for residents at high risk of falls
Wider context from the report “2. The evidence is clear that the provided sensor mat was not an efficient way of monitoring Mrs Savage when she attempted to mobilise . It was well known in the home that Mrs Savage defeated it's purpose by moving or unplugging it. There seems to have been a lack of thought as to an alternative measure . The wall mounted sensor, for example was seen by the expert as a reasonable measure - the home manager said he could consider them and the regional manager indicated they were used in the company, but not at the care home where Mrs Savage was residing. It seems to me the council should have an armoury of measures to pick from to tailor to the needs of the individual resident not just limited to one particular measure . The risk of death is obvious to others if persons at high risk of falls are not known to be moving by those charged with looking after them.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain timely medical advice after a resident fall
Wider context from the report “3. Mrs Savage's fall in February 2023 was it appears reported to her GP by her daughter and that led to a nurse attending the home to examine her. Staff at the home do not appear to have done so themselves. It is of concern that after a fall the staff within the home should have a mechanism to ensure medical advice is obtained in a timely fashion and that it is documented clearly and not be reliant on family members summoning help for residents themselves when they have become aware of an incident.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accessible and retained resident records
Wider context from the report “4. The absence of records has hindered my investigation into Mrs Savage's death. The expert in her evidence made it clear - good recording keeping allows staff to monitor changes in condition, allows new staff or those returning from time off to reacquaint themselves with residents condition and allows clinicians to make diagnosis - without access to good records I can see a clear risk to the care of residents . It is also surprising to me the complete reliance on paper records which in Mrs Savage’s case have been lost . I would have expected to see electronic recording of information and electronic storage of it. I note the roll out of this in the company has been paused whilst the company is awaiting sale and my concern is whether the electronic recording and storage will be implemented - to me immediate access to records of a resident or the absence of them creates a concern .
” Open source report
Concerns raised 6 Delays in completing and providing patient safety investigation reports View source Insufficient training coverage on capacity and best interests decision making across hospital settings View source Failure of patient safety investigations to comprehensively review anticoagulant omissions across hospital settings View source Failure to carry out capacity assessments and subsequent best interests decision making View source Failure to escalate anticoagulant omissions and related capacity issues View source Failure to consider alternative treatment to reduce DVT/PE risk View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Janet Rice · 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
Janet Rice, aged 65, died in hospital from pulmonary and cerebral embolism after surgery for a hip fracture sustained in an accidental fall. Anti-coagulant medication was inconsistently administered, including during a period when she was experiencing acute delirium; concerns included the absence of a capacity assessment, best-interests decision, escalation, or consideration of alternative treatment. The report also raised concerns about delays and limitations in the Trust’s patient safety investigation and the limited scope of related training.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in completing and providing patient safety investigation reports
Wider context from the report “(1) The final version of the patient safety investigation report carried out by the Trust was only received on the first day of the Inquest, some 16 months after the death . The concerns raised in this Inquest have been well known to the Trust for a considerable period of time and the concern is that lessons cannot be learned in a timely fashion if patient safety investigations are so significantly delayed .
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training coverage on capacity and best interests decision making across hospital settings
Wider context from the report “(3) Although evidence was heard in relation to the provision of further training in relation to the issues of capacity and best interests decision making , to address the concerns identified in this investigation this was limited to the community hospital setting, when it is known that the issues continued in the acute hospital setting .
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of patient safety investigations to comprehensively review anticoagulant omissions across hospital settings
Wider context from the report “(2) The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti coagulant and does not consider or address the omission to administer anti coagulant because the deceased was transferred between hospitals , nor does it detail all of the incidents of missed anti coagulant , some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti coagulant in the acute hospital setting , where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process, failure to escalate these issues, and/or to consider any alternative treatment to reduce the high risk of DVT/PE.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out capacity assessments and subsequent best interests decision making
Wider context from the report “(2) The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti coagulant and does not consider or address the omission to administer anti coagulant because the deceased was transferred between hospitals, nor does it detail all of the incidents of missed anti coagulant, some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti coagulant in the acute hospital setting, where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process , failure to escalate these issues, and/or to consider any alternative treatment to reduce the high risk of DVT/PE.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate anticoagulant omissions and related capacity issues
Wider context from the report “(2) The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti coagulant and does not consider or address the omission to administer anti coagulant because the deceased was transferred between hospitals, nor does it detail all of the incidents of missed anti coagulant, some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti coagulant in the acute hospital setting, where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process, failure to escalate these issues , and/or to consider any alternative treatment to reduce the high risk of DVT/PE.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider alternative treatment to reduce DVT/PE risk
Wider context from the report “(2) The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti coagulant and does not consider or address the omission to administer anti coagulant because the deceased was transferred between hospitals, nor does it detail all of the incidents of missed anti coagulant, some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti coagulant in the acute hospital setting, where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process, failure to escalate these issues, and/or to consider any alternative treatment to reduce the high risk of DVT/PE .
” 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 Review and update the patient safety investigation report and action plan to cover the patient’s acute and community care.
Verbatim wording from the response “The patient safety investigation report is not a comprehensive and robust review of the omissions in provision of anti-coagulant and does not consider or address the omission to administer anti-coagulant because the deceased was transferred between hospitals, nor does it detail all of the incidents of missed anti-coagulant, some of which only became apparent upon receipt of the independent expert report. It’s remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission to administer anti-coagulant in the acute hospital setting, where there was a continued failure to carry out a capacity assessment and any subsequent best interests decision making process, failure to escalate these issues, and/or to consider any alternative treatment to reduce the high risk of DVT/PE.” Source location Response from Durham and Darlington NHS
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 Track patient safety investigations at the weekly Senior Clinical Leaders patient safety forum.
Verbatim wording from the response “The Trust has robust processes in place in relation to the investigation of any patient safety incidents identified. When the Trust were made aware that there were patient safety concerns relating to Janet’s care, in April 2024, a review commenced of her care led by one of the Community matrons. The time taken to conclude and ensure the report had progressed through the appropriate Trust governance resulted in the report not being available to yourself until the morning of the inquest. However we recognise that this was not an acceptable timeframe to enable you to properly review the report. Whilst the progress of patient safety investigations have always been tracked by the corporate patient safety team, additional processes have now been established whereby these cases are tracked at the weekly Friday Senior Clinical Leaders patient safety forum.” Source location Response from Durham and Darlington NHS
Open published response
Concerns raised 5 Failure of acute, alcohol and drug treatment, and mental health teams to share crucial risk information appropriately View source Failure to ensure a robust safety plan upon discharge View source Failure of acute and mental health teams to consider contacting family or friends as an informal safety net View source Failure to determine whether discharge or step-down should be delayed until a place of safety is identified View source Lack of a protocol or policy for warning patients about acute respiratory depression and death risks from alcohol or drug misuse after administration of the drug View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew James Naylor · 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
Andrew James Naylor was found deceased on 11 October 2022 in Durham City, the day after discharge from hospital following treatment for a drug overdose and alcohol withdrawal. The report identified concerns about inadequate warnings of the risks associated with combining the administered drug with alcohol or drugs, poor communication between services, and insufficient consideration of his homelessness, discharge safety, and available support. The inquest concluded that he died from the combined central nervous system depressant actions of alcohol and two drugs, with cumulative failures contributing more than minimally to his 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of acute, alcohol and drug treatment, and mental health teams to share crucial risk information appropriately
Wider context from the report “(2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams , to consider the safety of a discharge, and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other's records ), and whether discharge should be delayed or care stepped down, until a place of safety is identified, and to ensure that a robust safety plan is in place upon discharge.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure a robust safety plan upon discharge
Wider context from the report “(2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams, to consider the safety of a discharge, and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other's records), and whether discharge should be delayed or care stepped down, until a place of safety is identified, and to ensure that a robust safety plan is in place upon discharge .
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of acute and mental health teams to consider contacting family or friends as an informal safety net
Wider context from the report “(3) There was no consideration given by either the acute or mental health teams to contacting the deceased’s family or friends , which may have provided an essential safety net in the absence of accessible professional support . The TEWV Trust are candid that work in relation to this issue is a work in progress and remains incomplete .
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to determine whether discharge or step-down should be delayed until a place of safety is identified
Wider context from the report “(2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams, to consider the safety of a discharge , and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other's records), and whether discharge should be delayed or care stepped down, until a place of safety is identified , and to ensure that a robust safety plan is in place upon discharge.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol or policy for warning patients about acute respiratory depression and death risks from alcohol or drug misuse after administration of the drug
Wider context from the report “(1) There is no specific protocol or policy in place to ensure that patients are warned of the acute risk of respiratory depression and death following administration of the drug ████████ should they drink alcohol or misuse drugs.
” Open source report
×
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 with clinical teams at huddles the importance of informing next of kin in comparable safety-risk scenarios.
Verbatim wording from the response “Whilst the Trust had next of kin contact details it is acknowledged that there is no evidence within Mr Naylors records that any attempt was made to contact them. As he had capacity our staff would not automatically have contacted them, however the importance of informing next of kin in scenarios such as Andrews has been reinforced to the clinical teams at huddles.” Source location Response from CDDFT
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 Review and update the acute alcohol withdrawal policy to include patient advice, using stakeholder input, and obtain approval by September 2024.
Verbatim wording from the response “The Trust has a Management of Acute Alcohol Withdrawal Policy which has been extended until September 2024 to enable the Organisation to explore the most appropriate, and safest, way to include the suggestion raised by yourself. This will require careful stakeholder” Source location Response from CDDFT
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 Because the patient had capacity, staff would not automatically contact next of kin, limiting routine family involvement without an identified basis.
Verbatim wording from the response “Whilst the Trust had next of kin contact details it is acknowledged that there is no evidence within Mr Naylors records that any attempt was made to contact them. As he had capacity our staff would not automatically have contacted them, however the importance of informing next of kin in scenarios such as Andrews has been reinforced to the clinical teams at huddles.” Source location Response from CDDFT
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 Existing clinical review, discharge documentation and policy-based follow-up arrangements were considered sufficient to address discharge safety concerns.
Verbatim wording from the response “Mr Naylor was reviewed by liaison psychiatry on the ward prior to discharge and it was documented by the team as being under the care of the community mental health team, who liaison psychiatry would request follow up by, and that he was safe for discharge. In relation to post discharge care, the Management of Acute Alcohol Withdrawal Policy details the follow up that should occur for the patients such as Mr Naylor, including referral on to specialist drug and alcohol teams and services and there was a plan for him to be followed up by the alcohol liaison service post discharge. In relation to his residential status, this was consistently documented as being in a named hostel during his admission.” Source location Response from CDDFT
Open published response
Concerns raised 1 Failure of medical records to make important information immediately visible and accessible to relevant clinicians View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gillian PEACOCK · 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
Gillian Peacock died at Darlington Memorial Hospital on 8 March 2023 after suffering a cardiac arrest during an admission for a chest infection. She had been prescribed digoxin and clarithromycin, and although a pharmacist recorded a warning about possible digoxin toxicity, no alternative drug was prescribed and monitoring did not occur until 7 March. The principal concern was that important information in medical records was not sufficiently visible or accessible to clinicians involved in the patient’s care.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of medical records to make important information immediately visible and accessible to relevant clinicians
Wider context from the report “The evidence I have heard is that the treating clinicians had not seen the entry in her medical records . This was in part due to the way the entries are displayed in the records and the 'huge' number of entries that are recorded .
I heard that now that any pharmacist entries of significance must be verbally passed to a junior doctor involved in the patient's care and in turn passed on at ward meetings to the broader group of staff caring for that patient.
I have a concern that the current system does not address the issue of important medical information being recorded in a patient's notes not being accessible in such a way that clinicians can see and if necessary act on it .
The use of verbal handovers does not in my view fully address my concern that crucial medical information should be recorded in a patient's medical records in such a way that relevant information is visible to those involved in care . In addition, that it can be accessed immediately without reliance on the verbal passing of information from one member of the treating team to another .
” Open source report
×
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 Convene a multidisciplinary cross-specialty group led by the Chief Pharmacist to review Major (level 2) drug interactions for potential prescriber alerts.
Verbatim wording from the response “Having taken into consideration your concerns the Trust is convening a multi-disciplinary, cross speciality group led by the Chief Pharmacist to review all Major (level 2) drug to drug interactions to review whether any are appropriate to activate a prescriber alert.” Source location Response from CDDFT
Open published response
Concerns raised 4 Failure to escalate pressure-wound issues to other services and professionals when needed View source Uncompleted further training for pressure-wound safety View source Failure to provide appropriate pressure-wound offloading advice and recommendations to families and carers View source Uncompleted pressure-wound safety protocols View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stanley Cummins · 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
Stanley Cummins, aged 84, died at home on 2 September 2022 after a heel pressure ulcer became necrotic and led to sepsis. The inquest identified concerns about failures to provide appropriate pressure relief and offloading advice, make referrals, and implement comprehensive changes to his care, with further training and protocols still described as work in progress.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate pressure-wound issues to other services and professionals when needed
Wider context from the report “During the Inquest I heard evidence from the Matron for Clinical Governance and Quality, responsible for the community nursing team responsible for Mr Cummins care, in relation to the work being undertaken to improve community nursing teams ability to comprehensively identify, record, treat and escalate, as necessary, pressure wounds.
I was not provided with comprehensive evidence that lessons had been learnt in relation to the accepted failings in this case, and in particular the failure by the District Nursing team to provide appropriate offloading advice and recommendations to family and carer’s in accordance with NICE guidelines, once pressure damage to the heel had been identified, or to escalate these issues as needed to other services and professionals .
The majority of the further training and protocols that the matron considered were appropriate to try to improve patient safety in relation to pressure wounds, were described to me as being a work in progress with no certainty as to when these would be completed.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Uncompleted further training for pressure-wound safety
Wider context from the report “During the Inquest I heard evidence from the Matron for Clinical Governance and Quality, responsible for the community nursing team responsible for Mr Cummins care, in relation to the work being undertaken to improve community nursing teams ability to comprehensively identify, record, treat and escalate, as necessary, pressure wounds.
I was not provided with comprehensive evidence that lessons had been learnt in relation to the accepted failings in this case, and in particular the failure by the District Nursing team to provide appropriate offloading advice and recommendations to family and carer’s in accordance with NICE guidelines, once pressure damage to the heel had been identified, or to escalate these issues as needed to other services and professionals.
The majority of the further training and protocols that the matron considered were appropriate to try to improve patient safety in relation to pressure wounds, were described to me as being a work in progress with no certainty as to when these would be completed .
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate pressure-wound offloading advice and recommendations to families and carers
Wider context from the report “During the Inquest I heard evidence from the Matron for Clinical Governance and Quality, responsible for the community nursing team responsible for Mr Cummins care, in relation to the work being undertaken to improve community nursing teams ability to comprehensively identify, record, treat and escalate, as necessary, pressure wounds.
I was not provided with comprehensive evidence that lessons had been learnt in relation to the accepted failings in this case, and in particular the failure by the District Nursing team to provide appropriate offloading advice and recommendations to family and carer’s in accordance with NICE guidelines, once pressure damage to the heel had been identified , or to escalate these issues as needed to other services and professionals.
The majority of the further training and protocols that the matron considered were appropriate to try to improve patient safety in relation to pressure wounds, were described to me as being a work in progress with no certainty as to when these would be completed.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Uncompleted pressure-wound safety protocols
Wider context from the report “During the Inquest I heard evidence from the Matron for Clinical Governance and Quality, responsible for the community nursing team responsible for Mr Cummins care, in relation to the work being undertaken to improve community nursing teams ability to comprehensively identify, record, treat and escalate, as necessary, pressure wounds.
I was not provided with comprehensive evidence that lessons had been learnt in relation to the accepted failings in this case, and in particular the failure by the District Nursing team to provide appropriate offloading advice and recommendations to family and carer’s in accordance with NICE guidelines, once pressure damage to the heel had been identified, or to escalate these issues as needed to other services and professionals.
The majority of the further training and protocols that the matron considered were appropriate to try to improve patient safety in relation to pressure wounds , were described to me as being a work in progress with no certainty as to when these would be completed .
” Open source report
×
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 Deliver community nursing study days covering updated wound documentation, equipment, incident reporting and heel off-loading.
Verbatim wording from the response “Study days have been booked for key staff in all community nursing teams for June 27th and 28th 2024. This will include the launch of the updated assessments and care plans, equipment updates, incident reporting updates and the use of heel off-loading.” Source location Response from County Durham and Darlington
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 patient and carer information leaflets about heel off-loading.
Verbatim wording from the response “Patient/carer information leaflets are also being developed regarding off-loading.” Source location Response from County Durham and Darlington
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 Review and update SystmOne wound assessments and care plans to include photography, heel off-loading advice and onward-referral guidance.
Verbatim wording from the response “The wound assessments and care plans in SystmOne are being reviewed and updated to include photography and advice re: off-loading and onward referrals.” Source location Response from County Durham and Darlington
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 Implemented and planned measures are considered sufficient to address concerns about learning, offloading advice, and escalation.
Verbatim wording from the response “We trust that the measures already implemented and those planned are sufficient to address the concerns you have highlighted. However, please feel free to contact us if you need any additional information or have further queries.” Source location Response from County Durham and Darlington
Open published response
Concerns raised 1 Failure of Emergency Department software to provide quick and clear identification of patient acuity View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emily Kate Harkleroad · 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
Emily Kate Harkleroad collapsed on 18 December 2022 and died from a pulmonary embolism in the early hours of 19 December 2022. The report states that failures and delays in treatment meant she did not receive anticoagulant treatment that, on a balance of probabilities, would have prevented her death. A further concern was that the Emergency Department’s new computer system lacked the previous clear RAG rating display for quickly identifying critically ill patients, particularly during periods of extreme pressure.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Emergency Department software to provide quick and clear identification of patient acuity
Wider context from the report “I heard evidence that in or around October 2022 a new computer system was introduced into the Emergency Department of the University Hospital of North Durham. The provider of the new system is Cerner. I understand that Cerner is now owned by Oracle Corporation. I heard evidence that the previous software in use in the Emergency Department included a “RAG rating” system, which ensured that the acuity of the patients was easily identifiable by looking at a single page on a display screen. I heard evidence that the new Cerner software did not include such a system. I understand that, instead, the Cerner software has symbols next to patient’s names that, when clicked on, provide an indication of the level of acuity of the patient, but not a clear indication at first glance. In summary, I was told that the previous RAG rating system was an effective tool in quickly identifying patients requiring urgent oversight by senior clinicians, especially when the Department was under extreme pressure. It is my view that, especially in times of extreme pressure on the Emergency Department, a quick and clear way of identifying the most critically ill patients is an important tool that could prevent future deaths. I was told that concerns about the absence of a RAG rating type system had been raised by a number of clinicians, but that the response, thus far, had been that the new system does not have that functionality.
” Open source report
×
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 Embed Medanets use through point-of-care support, formal training and regular compliance updates for Emergency Department staff.
Verbatim wording from the response “Improvement work since Go Live
In 2023, it was observed that ED teams were predominantly entering observations directly into Millennium via desktop computers, mirroring their previous method with Symphony, rather than utilising the provided mobile devices with the Medanets application. This practice results in a loss of decision support for the staff. In the case of Emily, two out of the three sets of observations taken were recorded directly into the desktop and not the Medanets application. Consequently, considerable efforts have been undertaken to ensure that ED staff fully utilise the mobile Zebra devices and, by extension, the Medanets application for recording observations in the ED. These efforts included providing support directly at the point of care, formal training, and regular updates on compliance through key messages.” Source location Response from County Durham and Darlington NHS Foundation Trust
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 Collaborate with Oracle Health on developing a Launchpoint column displaying colour-coded Early Warning Score RAG ratings.
Verbatim wording from the response “• Following your letter of 5th February 2024, and discussions with Oracle Health we have expanded that action plan to include collaboration with Oracle Health on the addition of a further column to the ED Screen, which will RAG-rate patients’ Early Warning Scores as ‘High’, ‘Medium’ or ‘Low’ with colour coding. It is understood that Oracle Health are looking to make this functionality available as part of their standard upgrade programme from around the middle of this year. We have not been able to further actions, either already implemented or in progress, to mitigate risk.” Source location Response from County Durham and Darlington NHS Foundation Trust
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 Use Medanets in Emergency Departments to record observations, calculate early warning scores, provide decision support and support patient escalation.
Verbatim wording from the response “• Medanets: A mobile application which enables staff to capture patient observations from hand-held devices, calculates national early warning scores (NEWS) and provides decision support for clinicians. The Emergency Department did not have this functionality prior to the implementation of Oracle Health and it was put in place to enhance patient safety. More information on Medanets is outlined below. It includes a RAG-rated view as shown in Appendix A.” Source location Response from County Durham and Darlington NHS Foundation Trust
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 Medanets and Launchpoint functionality was judged to mitigate the patient safety risk without the requested RAG-rated view.
Verbatim wording from the response “The ED team requested the same functionality as that in Symphony as part of the Oracle Health system at go-live and this request was discussed with Oracle Health’s work-stream lead who advised it was not feasible at that time. Taking account of the additional safety functionality introduced into the department through Medanets and the overall functionality of Launchpoint, the Trust judged the patient safety risk to be mitigated.” Source location Response from County Durham and Darlington NHS Foundation Trust
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 requested RAG-rated functionality could not be implemented at go-live because Oracle Health advised it was not feasible at that time.
Verbatim wording from the response “• We discussed with Oracle Health the potential to add and display RAG-ratings based on the patient’s Early Warning Score for go-live and, at that stage, advised by the work-stream leads allocated to the Trust that it was not possible. We subsequently logged a further request from the ED teams for this functionality, internally, to discuss with Oracle Health for future development.” Source location Response from County Durham and Darlington NHS Foundation Trust
Open published response
Concerns raised 2 Failure to provide patients with written instructions to resume anticoagulation View source Failure to ensure vulnerable or elderly patients understand the need to recommence medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret HEAL · 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
Margaret Heal died at home from a massive pulmonary thromboembolism caused by a deep venous thrombosis after stopping anticoagulant medication for surgery and not resuming it. The inquest found no evidence that she had been given written instructions to restart the medication, and raised concern about ensuring vulnerable or elderly patients living alone receive medication advice clearly.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide patients with written instructions to resume anticoagulation
Wider context from the report “During the course of the inquest it became apparent there was no evidence to show the deceased had been provided with a document instructing her to resume her anti coagulation . Whilst this requirement is set out in the Trust's procedures, no evidence was found it had taken place . No document was found in Mrs Heal's home at the time of her death . It is of concern that Mrs Heal was an 86 year old lady living alone after her discharge from hospital. Is there more that can be done to ensure patients particularly who are vulnerable and / or elderly are given advice regarding medication and drugs in a manner, to ensure as far possible, they are aware of the need to recommence their medication.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure vulnerable or elderly patients understand the need to recommence medication
Wider context from the report “During the course of the inquest it became apparent there was no evidence to show the deceased had been provided with a document instructing her to resume her anti coagulation. Whilst this requirement is set out in the Trust's procedures, no evidence was found it had taken place. No document was found in Mrs Heal's home at the time of her death. It is of concern that Mrs Heal was an 86 year old lady living alone after her discharge from hospital. Is there more that can be done to ensure patients particularly who are vulnerable and / or elderly are given advice regarding medication and drugs in a manner, to ensure as far possible, they are aware of the need to recommence their medication .
” Open source report
×
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 medication-restart instructions verbally at discharge and provide patients with written endoscopy reports containing the recommendations.
Verbatim wording from the response “Upon completion of an endoscopic procedure the discharging nurse goes through the results, follow up and recommendations with the patient (and usually with a family member too) prior to discharge. Information on starting medications is reinforced at that point and a copy of the report is provided to the patient which includes this information in writing. It should be noted that Mrs Heal's notes confirm that she received a copy of the endoscopy report and verbal information at the point of discharge.” Source location Response from County Durham and Darlington NHS
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 Provide pre-assessed patients with verbal and written medication-stopping advice, including an estimated restart timeframe.
Verbatim wording from the response “All patients who are pre-assessed are given advice and written information at the pre-assessment appointment, the pre-assessment team follow the BSG guidelines. The decision to restart the medication is made at the point of completing the procedure but the PA nurses will give an estimate at the time of pre-assessment of how long medications would be withheld in line with current recommendations.” Source location Response from County Durham and Darlington NHS
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 endoscopy processes are considered robust for communicating post-procedure medication instructions, so no additional measures are identified.
Verbatim wording from the response “It is our opinion that the process described above is a robust way of communicating post procedure instructions to our patients, if however, you have continued concerns then we would welcome the opportunity for a senior member of our patient safety team to meet with you to better understand the issues raised in the inquest, and to discuss the improvements that you feel may be necessary to address the issues identified.” Source location Response from County Durham and Darlington NHS
Open published response
3 Mar 2022 Mr Alan Hodgson · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 11 Insufficient dissemination, awareness and continuous training on the Vascular Pathway View source Failure to maintain continuity of care for vascular referrals View source Failure to follow the established Vascular Pathway View source Delays in CTA being performed View source Failure to ensure effective communications and handovers between staff View source Failure to ascertain the indication and appropriateness of opiate analgesia View source Inadequate CTA imaging View source Failure to report CTA findings urgently to requesting doctors View source Insufficiently robust review of deaths and lessons to be learnt View source Failure of the on-call Registrar to review a patient when called for advice View source Failure to ensure rapid escalation of care View source See 8 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
Mr Alan Hodgson · 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 Alan Hodgson died at Sunderland Royal Hospital on 14 January 2021. The report describes failures to recognise the severity of his condition, delays in acting on and reporting imaging, failures to follow the vascular pathway, inadequate communication and continuity of care, and an insufficient review of the circumstances leading to his 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient dissemination, awareness and continuous training on the Vascular Pathway
Wider context from the report “(6) An insufficiently robust review by The Trust of the circumstance leading to the death of Mr Alan Hodgson and of the lessons to be learnt from it, i.e. an insufficient review of the vascular pathway, including its dissemination, awareness and continuous training to improve the importance of the rapid escalation of care against the background of effective communications and handovers between staff to promote holistic patient care.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain continuity of care for vascular referrals
Wider context from the report “(5) Very poor standard of care in respect of continuity of care ; leaving the vascular referral to Sunderland to a very junior doctor on-call who did not even know the patient ;
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the established Vascular Pathway
Wider context from the report “(3) Failure by a Consultant Physician to follow an established Vascular Pathway despite clearly recognising the correct diagnosis of acute lower limb ischaemia;
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in CTA being performed
Wider context from the report “(4) Poor communication between medical and radiology doctors resulting in:
a) delays in CTA being performed ;
b) inadequate imaging being performed; and
c) a complete lack of urgency in reporting the findings of the CTA to the requesting doctors.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure effective communications and handovers between staff
Wider context from the report “(6) An insufficiently robust review by The Trust of the circumstance leading to the death of Mr Alan Hodgson and of the lessons to be learnt from it, i.e. an insufficient review of the vascular pathway, including its dissemination, awareness and continuous training to improve the importance of the rapid escalation of care against the background of effective communications and handovers between staff to promote holistic patient care.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ascertain the indication and appropriateness of opiate analgesia
Wider context from the report “(1) Signing and administration of opiate analgesia to a patient without any evidence of ascertaining why such analgesia was required, and if it was appropriate ;
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate CTA imaging
Wider context from the report “(4) Poor communication between medical and radiology doctors resulting in:
a) delays in CTA being performed;
b) inadequate imaging being performed ; and
c) a complete lack of urgency in reporting the findings of the CTA to the requesting doctors.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report CTA findings urgently to requesting doctors
Wider context from the report “(4) Poor communication between medical and radiology doctors resulting in:
a) delays in CTA being performed;
b) inadequate imaging being performed; and
c) a complete lack of urgency in reporting the findings of the CTA to the requesting doctors .
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust review of deaths and lessons to be learnt
Wider context from the report “(6) An insufficiently robust review by The Trust of the circumstance leading to the death of Mr Alan Hodgson and of the lessons to be learnt from it , i.e. an insufficient review of the vascular pathway, including its dissemination, awareness and continuous training to improve the importance of the rapid escalation of care against the background of effective communications and handovers between staff to promote holistic patient care.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the on-call Registrar to review a patient when called for advice
Wider context from the report “(2) Failure by the on-call Registrar to review a patient in the early hours of the morning when called for advice by the FY1 doctor ;
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure rapid escalation of care
Wider context from the report “(6) An insufficiently robust review by The Trust of the circumstance leading to the death of Mr Alan Hodgson and of the lessons to be learnt from it, i.e. an insufficient review of the vascular pathway, including its dissemination, awareness and continuous training to improve the importance of the rapid escalation of care against the background of effective communications and handovers between staff to promote holistic patient care.
” Open source report
Concerns raised 2 Failure of patient record systems to ensure timely communication of important and urgent information View source Failure to provide sufficient walking aids for vulnerable patients on hospital wards View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Agnes Gwenllian SANSOM · 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
Agnes Gwenllian Sansom was admitted to hospital on 15 July 2019 and, despite being at risk of falling and requiring supervision when mobilising, was not prevented from mobilising unaided. She fell on 20 July after nursing staff did not have access to important physiotherapy observations, sustaining the injury that led to her death; concerns included failures in patient information systems and the sharing of walking aids by vulnerable patients.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of patient record systems to ensure timely communication of important and urgent information
Wider context from the report “(i) existing patient record systems fail to ensure that important and urgent information is brought, in a timely way, to the attention of those who need it ;
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient walking aids for vulnerable patients on hospital wards
Wider context from the report “(ii) vulnerable patients are obliged to share walking aids on hospital wards
” Open source report
×
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 Maintain buffer stocks of walking aids in hospitals for emergency out-of-hours use.
Verbatim wording from the response “During traditional working hours walking aids are provided by physiotherapists following assessment of the patient. We have implemented a buffer stock of walking aids in the hospitals to ensure there is an adequate supply out of hours. Ideally the buffer stock should not be used as it is preferable that patients requiring a walking aid have a physiotherapist assessment first, however, if someone presents who does require a walking frame out of hours we have ensured that there is a buffer stock available for emergency use.” Source location Response from County Durham and Darlington NHS
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 Record changes in patient mobility or required interventions in Nevercentre’s mobility gallery.
Verbatim wording from the response “To address this issue physiotherapists now record in the mobility gallery in Nevercentre if they identify change in mobility or change in interventions required. This does not replace the detailed paper record but ensures that all staff are aware of this whether accessing paper records or Nevercentre.” Source location Response from County Durham and Darlington NHS
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 Nevercentre is not an electronic patient record; it is an electronic observations and risk-assessment system, while detailed care records remain paper-based.
Verbatim wording from the response “It is not factual to describe Nevercentre as an electronic patient record. The Trust does not have an electronic patient record in place. Nevercentre is an electronic observations system which is also used for some patient risk assessments; including falls risk assessment and mobility gallery.” Source location Response from County Durham and Darlington NHS
Open published response
Concerns raised 1 Risk of death associated with the drain View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Kane · 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
James Kane was admitted to hospital with gross ascites caused by advanced liver cirrhosis. A drain was inserted without an ultrasound scan on 2 January 2016, and after approximately 7.5 litres of fluid were drained, his condition deteriorated within an hour of the drain being removed; he died later on 3 January 2016. The principal concern was whether ultrasound scanning before drain insertion might have reduced the risk of bowel injury and death, despite there being no local support for changing existing policy or guidance.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of death associated with the drain
Wider context from the report “Notwithstanding that a local discussion of the circumstances of this case has taken place and there having been no local support for a change in policy or guidance, given the evidence that the deceased would not have died when he did but for the drain and that it is possible that a scan may have reduced the risk of death I believe this is a matter that requires further thought and consideration.
” Open source report
×
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 providing timely, safe paracentesis in accordance with national guidelines.
Verbatim wording from the response “1. To continue to provide a timely and safe service to all liver patients who require paracentesis in adherence to national guidelines. All trainees will be provided with a copy of the guidance.” Source location 2016-0253-Response-by-County-Durham-and-Darlington-NHS-Trust
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 Schedule all paracentesis procedures between 8am and 8pm to enable complication identification and escalation to a senior decision maker.
Verbatim wording from the response “3. All procedures will be performed between the hours of 8am and 8pm so that any complications can be identified and escalated to a senior decision maker.” Source location 2016-0253-Response-by-County-Durham-and-Darlington-NHS-Trust
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 paracentesis proforma and database to create a clear audit trail of procedures and complications.
Verbatim wording from the response “2. Ensure that there is a clear audit trail of patients having undergone paracentesis within CDDFT. This will include the development of a proforma and database which will include” Source location 2016-0253-Response-by-County-Durham-and-Darlington-NHS-Trust
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 Provide all trainees with copies of relevant paracentesis guidance.
Verbatim wording from the response “1. To continue to provide a timely and safe service to all liver patients who require paracentesis in adherence to national guidelines. All trainees will be provided with a copy of the guidance.” Source location 2016-0253-Response-by-County-Durham-and-Darlington-NHS-Trust
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 Routine ultrasound is not required because current departmental practice follows published guidance and uses ultrasound when clinically indicated.
Verbatim wording from the response “The current departmental practice is in keeping with published guidance in that paracentesis is normally done at the bedside with ultrasound guidance only being undertaken when there are concerns such as the presence of previous surgical scars or uncertainty on the presence of ascitic fluid. Ultrasound is not used routinely in large volume paracentesis in patients with liver cirrhosis who have well documented ascites and have previously undergone paracentesis.” Source location 2016-0253-Response-by-County-Durham-and-Darlington-NHS-Trust
Open published response
Concerns raised 6 Failure to prescribe and record oxygen flow rates on the drug chart View source Failure to investigate oxygen concentrator incidents View source Failure to ensure administration of oxygen at the prescribed rate View source Failure to report oxygen concentrator incidents to the manufacturer View source Failure to specify action when an oxygen concentrator is not working correctly View source Failure to specify checks of oxygen concentrator output View source See 3 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
Mr Matthews · 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 Matthews, who had pneumoconiosis and COPD, was admitted to hospital after being found collapsed and later suffered further cardiac arrests before dying on 19 February 2016. The principal concerns were that oxygen was not prescribed or recorded at the required rate, and that there was no system to ensure the oxygen concentrator was working correctly or that damage to it was promptly reported and investigated.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe and record oxygen flow rates on the drug chart
Wider context from the report “(2) Notwithstanding the conclusion of the manufactuer that the oxygen was still being delivered by the device in the right concentration, I am concerned that there was no system in place to ensure that the oxygen was being administered at the prescribed rate. An oxygen concentrator had been set up for use by the patient and the flow rate had been set at 2 litres per minute. The Trust's policy states that all oxygen must be prescribed and the prescribed rate should be recorded on the drug chart. The oxygen was not prescribed on the drug chart and the flow rate was not recorded . This meant that staff were unaware of the prescribed rate and there was no means of checking that the concentrator was delivering the prescribed flow rate.
(3) The Trust's policy for oxygen states that oxygen must be prescribed and that the prescribed rate should be recorded on the drug chart. However, no such prescription was made in the drug chart and no record was made of the flow rate .
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate oxygen concentrator incidents
Wider context from the report “(4) The Clinical Engineering Team Leader and the manufacturer concur that the damage to the oxygen concentrator was caused by an accident and that the damage was not responsible for the death. Nevertheless, I am concerned that the incident was not reported to the manufacturer at the time and that no investigation was carried out . The Trust has subsequently reviewed its incident reporting policy and the manufacturer has reviewed its own policy.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure administration of oxygen at the prescribed rate
Wider context from the report “(2) Notwithstanding the conclusion of the manufactuer that the oxygen was still being delivered by the device in the right concentration, I am concerned that there was no system in place to ensure that the oxygen was being administered at the prescribed rate . An oxygen concentrator had been set up for use by the patient and the flow rate had been set at 2 litres per minute. The Trust's policy states that all oxygen must be prescribed and the prescribed rate should be recorded on the drug chart. The oxygen was not prescribed on the drug chart and the flow rate was not recorded. This meant that staff were unaware of the prescribed rate and there was no means of checking that the concentrator was delivering the prescribed flow rate .
(3) The Trust's policy for oxygen states that oxygen must be prescribed and that the prescribed rate should be recorded on the drug chart. However, no such prescription was made in the drug chart and no record was made of the flow rate.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report oxygen concentrator incidents to the manufacturer
Wider context from the report “(4) The Clinical Engineering Team Leader and the manufacturer concur that the damage to the oxygen concentrator was caused by an accident and that the damage was not responsible for the death. Nevertheless, I am concerned that the incident was not reported to the manufacturer at the time and that no investigation was carried out. The Trust has subsequently reviewed its incident reporting policy and the manufacturer has reviewed its own policy.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to specify action when an oxygen concentrator is not working correctly
Wider context from the report “(5) There was no system in place to ensure that the oxygen concentrator was working correctly. It does not state precisely how to check the amount of oxygen delivered by the device, nor does it state what action should be taken if the device is not working correctly .
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to specify checks of oxygen concentrator output
Wider context from the report “(5) There was no system in place to ensure that the oxygen concentrator was working correctly . It does not state precisely how to check the amount of oxygen delivered by the device , nor does it state what action should be taken if the device is not working correctly.
” Open source report
Concerns raised 1 Delays in diagnosing fractures during regular clinical visits and examinations View source
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
Elsie Raper · 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
Elsie Raper, who had osteoporosis and lived in a care home, suffered multiple falls and fractures, including fractures of the left tibia and fibula after a fall on 21 August 2015. These fractures were not diagnosed until 25 August, during which time she was reported to have been in extreme pain; the cause of death included multiple fractures.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in diagnosing fractures during regular clinical visits and examinations
Wider context from the report “(1) That Elsie Raper, being a patient and being subject to regular visits and examination by GP's and nurses , suffered a fracture to her left tibia and left fibula probably on 21st August 2015, which remained undiagnosed until the 25th August 2015 .
” Open source report
23 Oct 2015 Margaret Anne Ferry · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 6 Lack of an inter-trust policy clarifying responsibility and communication channels for referred patients View source Poor direct and indirect communication between medical professionals at different trusts View source Lack of a policy clarifying responsibilities and communication channels between trusts when patients are referred View source Poor understanding between medical professionals of differing practices and procedures View source Poor understanding of differing practices and procedures between trusts View source Poor direct and indirect communication between medical professionals across trusts View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Anne Ferry · 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
Margaret Anne Ferry was admitted to Sunderland Royal Hospital, underwent a planned toe amputation, and subsequently developed deterioration in her skin integrity before dying on 12 May 2015. The report identified unclear responsibilities between hospitals, poor written and oral communication, differing practices and procedures, and a lack of leadership and a cohesive treatment plan.
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× 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an inter-trust policy clarifying responsibility and communication channels for referred patients
Wider context from the report “1. Evidence was given at the Inquest that there was no policy in place between City Hospitals Sunderland NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust clarifying the areas of responsibility and channels of communication between the two when patients are referred .
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor direct and indirect communication between medical professionals at different trusts
Wider context from the report “2. Evidence was given that there were poor levels of communication both direct and indirect between medical professionals at each trust and poor understanding of each other’s differing practices and procedures.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy clarifying responsibilities and communication channels between trusts when patients are referred
Wider context from the report “1. Evidence was given at the Inquest that there was no policy in place between City Hospitals Sunderland NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust clarifying the areas of responsibility and channels of communication between the two when patients are referred .
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor understanding between medical professionals of differing practices and procedures
Wider context from the report “2. Evidence was given that there were poor levels of communication both direct and indirect between medical professionals at each trust and poor understanding of each other’s differing practices and procedures .
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor understanding of differing practices and procedures between trusts
Wider context from the report “2. Evidence was given that there were poor levels of communication both direct and indirect between medical professionals at each trust and poor understanding of each other’s differing practices and procedures .
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor direct and indirect communication between medical professionals across trusts
Wider context from the report “2. Evidence was given that there were poor levels of communication both direct and indirect between medical professionals at each trust and poor understanding of each other’s differing practices and procedures.
” Open source report
×
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 and establish a standing operational procedure governing inter-organisational plastic surgery referrals, including documentation, response timescales and care responsibilities.
Verbatim wording from the response “We have recognised that there were significant gaps in the provision of services to Margaret therefore, Anne Ferry, City Hospitals Sunderland, and the Trust have worked closely with our colleagues at City Hospital Sunderland to address the issues raised. In collaboration we have developed a new standing operational procedure to provide a comprehensive approach to inter organisational referrals for plastic surgery opinions. The standard procedure provides a process to ensure that the referral is clearly documented; that a suitable response is provided within clearly defined timescales, and that it is clear to all parties that patients on wards at Sunderland Royal remain under the care of the admitting consultant at all times, and not the plastics team. I have included this for your information.” Source location 2015-0450-Response
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 Patients on Sunderland Royal wards remain under the admitting consultant’s care, not the plastics team’s responsibility.
Verbatim wording from the response “We have recognised that there were significant gaps in the provision of services to Margaret therefore, Anne Ferry, City Hospitals Sunderland, and the Trust have worked closely with our colleagues at City Hospital Sunderland to address the issues raised. In collaboration we have developed a new standing operational procedure to provide a comprehensive approach to inter organisational referrals for plastic surgery opinions. The standard procedure provides a process to ensure that the referral is clearly documented; that a suitable response is provided within clearly defined timescales, and that it is clear to all parties that patients on wards at Sunderland Royal remain under the care of the admitting consultant at all times, and not the plastics team. I have included this for your information.” Source location 2015-0450-Response
Open published response
Concerns raised 1 Failure to provide community hospital staff with access to emergency advice from an appropriate expert View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
PATRICIA LILLIAN CHAPMAN · 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
PATRICIA LILLIAN CHAPMAN was a patient at Sedgefield Community Hospital who suffered a severe hypoglycaemic attack on 8 July 2013 and died from another hypoglycaemic attack early the following day. The inquest identified shortcomings in her care and concluded that her death was the avoidable consequence of an avoidable hypoglycaemic episode. A substantive concern was that revised policies did not address obtaining immediate emergency advice from an appropriate expert for community hospital staff.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide community hospital staff with access to emergency advice from an appropriate expert
Wider context from the report “(1) The revised training and flow chart does not include any reference to staff in a community hospital being able to obtain emergency advise from an expert in the emergency department of one of the Trust’s acute hospitals (or from an expert in another department of the said hospitals if appropriate) to assist in giving immediate medical cover whilst, for example, other steps are being taken or whilst an ambulance is on route after having been summoned. It may well be the case that in urgent situations immediate medical advice from an appropriate expert might be beneficial when trying to ensure a patient's safety and this is not included in the revised Trust policies . This is something that should be given consideration to.
” 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 Introduce an operational procedure enabling community hospital staff to obtain urgent acute-hospital medical advice while awaiting an ambulance.
Verbatim wording from the response “We have also introduced an operational procedure for community hospital staff who may require urgent advice whilst waiting for an ambulance to arrive, as follows:” Source location 2015-0159-Response-by-County-Durham-and-Darlington-NHS-Trust
Open published response
Concerns raised 2 Failure to provide structured monitoring or formal observations during delayed discharge View source Lack of formal policy or written guidance for safe late-at-night discharge decisions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrea Jane Thirkell · 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
Andrea Jane Thirkell had an unwitnessed fall at a nursing home and was taken to hospital, where she was deemed fit for discharge but remained in the department for several hours without structured monitoring or observation. She returned to the nursing home, was found unresponsive, and was later diagnosed at hospital with a serious head injury before dying later that day. Concerns related to the lack of formal monitoring during delayed discharge and the absence of formal guidance for late-night discharges, which could result in inconsistent or potentially erroneous decisions.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide structured monitoring or formal observations during delayed discharge
Wider context from the report “(1) Although considered to be medically fit for discharge at 19.25 hours she did not leave the department until 23.03 and during that time she was not subject to any structured form of monitoring or observation although nursing staff may have seen her during that time. Evidence was given that since this incident staff have been reminded that patients should be subject to formal observations if there is a delay in discharge . Although I was told this I am unclear as to whether there is a formal trust policy in place in this regard.
” 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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal policy or written guidance for safe late-at-night discharge decisions
Wider context from the report “(2) The deceased did not leave the department until 23.03. Evidence was given that it is common for patients to be discharged late on a night either home or to a care home knowing that there is likely to be nursing care available. The evidence I heard was that there was no formal trust policy or written guidance with regard to the issue of late at night discharge and what other factors need to be taken account of in considering whether it is safe to discharge a patient at such time and in what circumstances . The evidence was that each senior doctor will apply his or her own medical discretion and combined with the pressures on a busy department I am concerned that this could lead to inconsistent or potentially erroneous decisions being made .
” Open source report
×
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 Amend the Trust’s Going Home Policy to specify Emergency Department discharge procedures, including discharges after 22:00.
Verbatim wording from the response “This change in practice will be implemented immediately. Amendments have also been made to the Trusts ‘Going Home Policy’ (POL/NG/0005A), to reflect the discharge procedure from the Emergency Department including discharges after 22.00 hours. This was discussed and approved at the Trust’s Executive Clinical Lead meeting on 21st May 2015 and will be discussed at the Quality and Healthcare Governance meeting in June 2015. The change in practice will be implemented immediately and audited as part of the routine Symphony records audit in which three sets of notes are audited daily for completeness.” Source location Thirkell-R2015-0124
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 Implement discharge-time observations, apply the Early Warning Score protocol when necessary, and record the results in Symphony, with routine audit of record completeness.
Verbatim wording from the response “The issue you have raised was discussed at the Emergency Department senior staff meeting at the University Hospital North Durham which convened on 23 April 2015 and was subsequently discussed and agreed by the Emergency Department at Darlington Memorial Hospital. The consensus of opinion was that at the time of leaving the department it would have been sensible for a member of the team to have undertaken a set of observations on the patient, to act upon these if necessary as per the Early Warning Score (EWS) protocol and then to record these in the allotted field on Symphony (the Emergency Department electronic notes system). In addition there is also a field in Symphony, under the transport Data Entry Protocol (DEP), which the team member is able to utilise to record the name of the person to whom the patient is returning.” Source location Thirkell-R2015-0124
Open published response
Concerns raised 1 Lack of a presumption of increased falls risk for certain classes of patients in falls risk assessments View source
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
Thomas Luke-Taylor · 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
Thomas Luke-Taylor, who had suffered a stroke, fell from his bed while in the Stroke Rehabilitation Ward at Bishop Auckland General Hospital, sustained a head injury and subsequently died. Concerns were raised about incorrect falls-risk assessments, inadequate supervision of a student nurse, and whether certain patients such as stroke patients should be presumed to be at increased risk of falls unless there were good reasons otherwise.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a presumption of increased falls risk for certain classes of patients in falls risk assessments
Wider context from the report “In evidence the Matron was asked whether it might be preferable for the falls risk assessment form to give a presumption that certain classes of patients (for example stroke patients) were at increased risk of falls and should be considered as such unless there were good reasons to the contrary . It was her view that this would not be good practice as each and every patient should be assessed on an individual basis. Whilst that is a laudable outlook it was put to her that if there had been such a presumption then the misclassification by the original staff nurse and by the student nurse might have been avoided and this could lead either in this case or in other cases to a potentially different outcome. The matron's view was that freedom of assessment was nevertheless best practice. I indicated my concern over this issue as to whether there should be a presumption in certain cases of an increased risk of falls and that consideration of this issue would be useful.
” Open source report
Concerns raised 1 Failure to undertake rectal biopsy for diagnosis of Hirschsprung’s disease View source
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
Nathan Douthwaite · 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
Nathan Douthwaite had a long history of severe constipation requiring repeated hospital admissions and died after emergency admission in December 2010. Autopsy found massive megacolon with abdominal compartment syndrome and a perforated caecum, with Hirschsprung’s disease recorded as an underlying cause. The report raised concerns that a rectal biopsy might have diagnosed Hirschsprung’s disease and identified a need to review relevant guidelines and clinical practices.
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 County Durham and Darlington NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake rectal biopsy for diagnosis of Hirschsprung’s disease
Wider context from the report “It is likely that if Nathan had undergone a rectal biopsy, Hirschsprung’s disease would have been diagnosed with the opportunity then being available for the appropriate treatment and thus I consider
(1) That NICE undertake a review of its guidelines in this regard
(2) That Count Durham and Darlington NHS Trust does review its own practices and procedures in avoidance of a NICE review and
(3) The Department of Health be aware of the circumstances of this case so that it can consider whether guidance should be issued in this regard pending the NICE review.
” 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