Recipient

Croydon Health Services NHS Trust

First report 8 Dec 2015•Latest report 1 Sep 2021

Recipient record

Reports, concerns and published responses

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

Reports: 3
Published responses: 67%
Concerns addressed: 3
Stated actions: 8

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

67%published responses found

8stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Croydon Health Services NHS Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

1 Sep2021
South London
Concerns raised2
1. Failure to seek guidance on managing resistance to turning
2. Lack of skin integrity assessments and preventive measures in A&E
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Cascade pressure-ulcer prevention initiatives and new actions effectively across all clinical departments.
  Stated planned
2. Action
  Roll out the agreed pressure-ulcer prevention actions across the organisation.
  Stated completed
3. Action
  Place monitoring and evaluation of the actions on the monthly pressure-ulcer prevention meeting agenda for at least three months.
  Stated planned
AI-generated summary

John Willis Humphries · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

John Willis Humphries was admitted to hospital with abdominal pain and developed pressure sores, which deteriorated during his stay. He was later readmitted, developed recurrent urinary tract infections associated with catheterisation, and died from pulmonary oedema and pneumonia. Concerns included the absence of reported skin integrity assessments or measures in the Emergency Department and the failure to seek advice on managing his resistance to repositioning.

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 Croydon Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to seek guidance on managing resistance to turning
Wider context from the report
“(2) When Mr Humphries resisted being turned, no advice was sought from external professionals or the nursing home as to how to manage the situation. The nursing home in particular had effectively employed a range of strategies to deal with the situation and would have been able to provide guidance had the staff been contacted. ”
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 Croydon Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of skin integrity assessments and preventive measures in A&E
Wider context from the report
“(1) I heard evidence that Mr Humphries’ pressure sore probably started in A&E where he stayed for a long period before being moved to a ward. I was not informed of any skin integrity assessments or measures whilst he was in A&E. ”
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
Cascade pressure-ulcer prevention initiatives and new actions effectively across all clinical departments.

Verbatim wording from the response
“• Communication of all the initiatives and new actions from the Pressure Ulcer prevention group to be effectively cascades to all departments”

Source location
2021-0291-Response-from-Croydon-Health-Services-NHS-Trust
Page 2 · response
Published 9 September 2021
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
Roll out the agreed pressure-ulcer prevention actions across the organisation.

Verbatim wording from the response
“6. Agreed Actions: Although there was a particular focus in the Emergency Department and Fairfield 1 in response to this PFD the actions have been rolled out across the organisation.”

Source location
2021-0291-Response-from-Croydon-Health-Services-NHS-Trust
Page 1 · response
Published 9 September 2021
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
Place monitoring and evaluation of the actions on the monthly pressure-ulcer prevention meeting agenda for at least three months.

Verbatim wording from the response
“5. Response of Pressure Ulcer Reduction group: Following the receipt of the PFD the Organisations Pressure Ulcer Prevention group met on the 22nd September 2021 to discuss and review the immediate actions but in place by the Associate Director of Nursing as an immediate response to the notification.”

Source location
2021-0291-Response-from-Croydon-Health-Services-NHS-Trust
Page 1 · response
Published 9 September 2021
Open published response
28 Apr2016
Inner West London
Concerns raised5
1. Problems with systems for the administration of blood
2. Problems with telephonic communications on the CUH site
3. Lack of nursing staff training on the existence of and when to call the site or critical outreach team
1. Lack of a bedside observation chart that assists clinical assessment of patients
2. Lack of timely escalation of clinical concerns from junior to senior staff
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

Laxmi Himatlall THAKKER · 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

Laxmi Himatlall Thakker fell at home and was admitted to Croydon University Hospital, where her deterioration after surgery was not recognised promptly. She collapsed and was not diagnosed or treated for bleeding and vascular injury until several hours later, was transferred to St George’s Hospital in critical condition, and died in intensive care on 29 September 2014. The principal concerns included the lack of bedside observation charts, failures to escalate concerns, communication and training problems, delays in administering blood, and inadequate escalation to senior 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 Croydon Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Problems with systems for the administration of blood
Wider context from the report
“4. Problems with systems in place for the administration of blood at CUH. ”
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 Croydon Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Problems with telephonic communications on the CUH site
Wider context from the report
“3. Problems with telephonic communications on the CUH site. ”
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 Croydon Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of nursing staff training on the existence of and when to call the site or critical outreach team
Wider context from the report
“2. Lack of training at CUH in the nursing staff in relation to the existence of and when to call the “site” or “critical outreach team”. ”
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 Croydon Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of a bedside observation chart that assists clinical assessment of patients
Wider context from the report
“1. Lack of bedside observation chart hinders rather than assists clinical assessment of patients. This represents a real step- back in the provision of 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 Croydon Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of timely escalation of clinical concerns from junior to senior staff
Wider context from the report
“5. Lack of escalation of clinical concerns from junior to senior staff at CUH, and in particular that a patient could collapse, be seen by a junior from another treating team and the patient’s own senior team not be promptly informed, as well lack of escalation of clinical issues within the same team. ”
Open source report
8 Dec2015
South London
Concerns raised2
1. Failure to assess emergency department patients consistently regardless of mode of transport
2. Insufficient qualification for assessment of urgent care patients
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Deliver UCC streaming through senior emergency department nurses.
  Stated completed
2. Action
  Hold fortnightly governance meetings between the UCC and emergency department to review and refine governance, streaming, and handover processes.
  Stated completed
Respondent positions 1
1. Position
  Responsibility for the urgent-care streaming model and related actions rests with Virgin Care Wandle LLP, not the Trust.
  Redirects responsibility
AI-generated summary

Madhumita Mandal · 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

Madhumita Mandal became unwell and attended Croydon University Hospital on 7 September 2013, where the inquest recorded multiple organ failure due to sepsis associated with a ruptured endometriotic ovarian cyst. The principal concerns were delays in assessment and treatment, including initial streaming by a receptionist without medical training, and failures in clinical supervision. The report also raised concerns about differing assessment based on whether patients arrived by ambulance.

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 Croydon Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to assess emergency department patients consistently regardless of mode of transport
Wider context from the report
“Mrs Mandal’s death also raises questions about the use of ambulance services. A difference in assessment of patients based upon their mode of transport to the emergency department may encourage patients to err on the side of calling an ambulance. ”
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 Croydon Health Services NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Insufficient qualification for assessment of urgent care patients
Wider context from the report
“Mrs Mandal was taken to Croydon University Hospital by her husband. Virgin Care was contracted by the Croydon Clinical Commissioning Group to provide urgent care services, and to stream adult patients arriving at the emergency department. A streaming model was followed by a receptionist who had no medical training and who performed no medical observations. This led to a delay of about an hour before Mrs Mandal was seen by any qualified healthcare professional, by which time her condition was critical. The streaming model had been approved and commissioned in the contract as recommended by an NHS body called the Emergency Care Intensive Support Team. The system at Croydon has changed since Mrs Mandal’s death but concerns remain about the level of qualification for assessment of patients, and there may be lessons for other Trusts who contract out the provision of urgent care. ”
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 UCC streaming through senior emergency department nurses.

Verbatim wording from the response
“1. Medical observation reviews in UCC The streaming model currently in place between the UCC and the Trust’s emergency department is now delivered by band 6/7 (senior) emergency department nurses.”

Source location
MMandal-Response2
Page 2 · response
Published 8 December 2015
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
Hold fortnightly governance meetings between the UCC and emergency department to review and refine governance, streaming, and handover processes.

Verbatim wording from the response
“3. Fortnightly governance review meeting There is now a fortnightly review of governance and process issues between the UCC and the emergency department; this has allowed us to work more closely with our UCC colleagues and recognise and deal with potential problems more quickly. We have used the forums to refine the streaming and handover processes thus ensuring patients get to the correct clinicians in a safe and timely fashion.”

Source location
MMandal-Response2
Page 2 · response
Published 8 December 2015
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
Responsibility for the urgent-care streaming model and related actions rests with Virgin Care Wandle LLP, not the Trust.

Verbatim wording from the response
“The Croydon Clinical Commissioning Group (“CCG”) awarded the contract for delivery of urgent care services to Virgin Care Wandle LLP. Virgin Care Wandle LLP controlled the steaming of adult patients who arrived in the Trust’s Emergency Department at the time of the incident. The functionality and review of the streaming model at the time of the incident is accordingly the responsibility of Virgin Care Wandle LLP.”

Source location
MMandal-Response2
Page 1 · response
Published 8 December 2015
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Failure to seek guidance on managing resistance to turning

Lack of skin integrity assessments and preventive measures in A&E

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised5

Problems with systems for the administration of blood

Problems with telephonic communications on the CUH site

Lack of nursing staff training on the existence of and when to call the site or critical outreach team

Lack of a bedside observation chart that assists clinical assessment of patients

Lack of timely escalation of clinical concerns from junior to senior staff

Concerns raised2

Failure to assess emergency department patients consistently regardless of mode of transport

Insufficient qualification for assessment of urgent care patients

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 3

Actions described in response 2

Respondent positions 1