25 Mar 2015 Bryan Herbert Whitby · Prevention of Future Deaths report Manchester South
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Concerns raised 11 Failure of biochemistry laboratories to escalate blood test results View source Failure to provide radiologists with current blood results before scanning View source Insufficient critical care nurse capacity for immediate High Dependency Unit transfer View source Failure to manage metformin medication before CT scanning View source Failure to record who requested further blood tests View source Failure of treating medical staff to recognise serious medical conditions View source Failure to escalate blood test results View source Failure to carry out required medical treatment View source Failure of GP practices to know the timing of referred CT scans View source Delays in recognising serious blood-test results View source Failure to admit patients as emergencies despite serious blood-test results View source See 8 more concerns
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Bryan Herbert Whitby · 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
Bryan Herbert Whitby had chronic kidney disease and underwent a CT scan while his renal function was deteriorating and he was taking metformin. After the scan, further deterioration was identified, but there were delays and failures in escalating the results, arranging urgent admission, recognising his serious condition, providing treatment, and transferring him to the High Dependency Unit; he died shortly after admission there. The principal concerns included communication and escalation failures, inadequate recognition and treatment of acute illness, and delayed critical-care transfer.
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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 Davyhulme Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure of biochemistry laboratories to escalate blood test results
Wider context from the report “4. The results of the blood tests on the 6th May should have resulted in urgent discussion with the deceased’s GP or the deceased himself. There was no escalation of these results by the biochemistry laboratory .
” 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 Davyhulme Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to provide radiologists with current blood results before scanning
Wider context from the report “2. Blood tests taken on the 2nd May were not escalated by the GP or the pathology laboratory and the scan on the 3rd May went ahead whilst he was still receiving metformin medication. The radiologist carrying out the scan did not have access to his blood results from the 2nd May and simply went off the results from the GP referral some time ago .
” 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 Davyhulme Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Insufficient critical care nurse capacity for immediate High Dependency Unit transfer
Wider context from the report “7. The Inquest also heard evidence that Mr Whitby required transfer to the High Dependency Unit but this could not take place immediately as two critical care nurses were required and one had been sent to Manchester Royal Infirmary as was the practice if there were no patients in the HDU at the start of their shift.
” 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 Davyhulme Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to manage metformin medication before CT scanning
Wider context from the report “2. Blood tests taken on the 2nd May were not escalated by the GP or the pathology laboratory and the scan on the 3rd May went ahead whilst he was still receiving metformin medication . The radiologist carrying out the scan did not have access to his blood results from the 2nd May and simply went off the results from the GP referral some time ago.
” 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 Davyhulme Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to record who requested further blood tests
Wider context from the report “3. There is no record of who requested further blood tests on the 6th May .
” 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 Davyhulme Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure of treating medical staff to recognise serious medical conditions
Wider context from the report “6. When he was admitted into hospital there was a failure by the treating medical staff to recognise his serious medical condition and then a failure to carry out the required medical treatment.
” 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 Davyhulme Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate blood test results
Wider context from the report “2. Blood tests taken on the 2nd May were not escalated by the GP or the pathology laboratory and the scan on the 3rd May went ahead whilst he was still receiving metformin medication. The radiologist carrying out the scan did not have access to his blood results from the 2nd May and simply went off the results from the GP referral some time ago.
” 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 Davyhulme Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out required medical treatment
Wider context from the report “6. When he was admitted into hospital there was a failure by the treating medical staff to recognise his serious medical condition and then a failure to carry out the required medical treatment .
” 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 Davyhulme Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure of GP practices to know the timing of referred CT scans
Wider context from the report “1. The deceased had been unwell for some time and had a history of Chronic Kidney Disease Stage 3. He had been referred for a CT scan but the GP Practice were not aware of the date of the scan or that this would take place on the 3rd May .
” 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 Davyhulme Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Delays in recognising serious blood-test results
Wider context from the report “5. Despite the blood results, the deceased was not admitted to hospital as an emergency and there was a delay in recognising the seriousness of these results . I had given evidence that training for junior members of staff on acute kidney injury has now been delivered.
” 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 Davyhulme Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to admit patients as emergencies despite serious blood-test results
Wider context from the report “5. Despite the blood results, the deceased was not admitted to hospital as an emergency and there was a delay in recognising the seriousness of these results. I had given evidence that training for junior members of staff on acute kidney injury has now been delivered.
” 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 the practice policy for allocating and checking incoming test results in light of the case.
Verbatim wording from the response “Mr Whitby’s case was discussed at a Significant Event meeting at the practice and has been further discussed by the GP’s and managers in recent weeks. Attached is a bullet point list of the actions that we have and will undertake related to this. In line with normal practice across the Primary care sector we have not in the past had a policy of checking every result on the day that it arrives. We have felt that there was a strong argument to maintain a level of continuity of care with results being seen by the GP who has ordered them but we have now reviewed this policy in light of Mr Whitby’s case.” Source location 2015-0121-Response-by-Davyhulme-Medical-Centre
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have all practice GPs read NICE guidance on acute kidney injury to improve management and awareness.
Verbatim wording from the response “It was also clarified that as a practice we are not able to see results put on to the hospital system automatically unless we search for them on a named patient basis. We do not automatically know about abnormal results in the hospital therefore. In fact ████████ who noted the abnormal results did ring the medical registrar to obtain further advice. As a result of the significant event meeting it was agreed that all GP’s would read the NICE Guidance on acute kidney injury to improve our management and awareness of this condition in the future. The need to consider stopping medication potentially toxic to the kidney in high risk patients was highlighted, as was the need to check blood results on a daily basis to avoid missing abnormal results.” Source location 2015-0121-Response-by-Davyhulme-Medical-Centre
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The practice relies on the laboratory to telephone urgent abnormal results, which are passed to the on-call doctor and dealt with that day.
Verbatim wording from the response “The practice relies upon the lab to phone through any abnormal results if urgent attention is required. These are then passed onto the on call doctor and are dealt with on the day. It was not felt practical to be able to guarantee to check all results as they come in continuously. Neither this nor the subsequent kidney function result was phoned through as urgent. We understood from the hospital critical incident report that the lab at Trafford General was aware of this and would be reviewing this system. It was also felt that in view of a previous drop in renal function to a lower level of 34, which had subsequently recovered, most of the GP’s felt they would have arranged to repeat the blood test in the first instance.” Source location 2015-0121-Response-by-Davyhulme-Medical-Centre
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The practice cannot automatically see hospital results and would need to search for them using a named-patient basis.
Verbatim wording from the response “It was also clarified that as a practice we are not able to see results put on to the hospital system automatically unless we search for them on a named patient basis. We do not automatically know about abnormal results in the hospital therefore. In fact ████████ who noted the abnormal results did ring the medical registrar to obtain further advice. As a result of the significant event meeting it was agreed that all GP’s would read the NICE Guidance on acute kidney injury to improve our management and awareness of this condition in the future. The need to consider stopping medication potentially toxic to the kidney in high risk patients was highlighted, as was the need to check blood results on a daily basis to avoid missing abnormal results.” Source location 2015-0121-Response-by-Davyhulme-Medical-Centre
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The practice considers it impractical to guarantee that all results are checked continuously as they arrive.
Verbatim wording from the response “The practice relies upon the lab to phone through any abnormal results if urgent attention is required. These are then passed onto the on call doctor and are dealt with on the day. It was not felt practical to be able to guarantee to check all results as they come in continuously. Neither this nor the subsequent kidney function result was phoned through as urgent. We understood from the hospital critical incident report that the lab at Trafford General was aware of this and would be reviewing this system. It was also felt that in view of a previous drop in renal function to a lower level of 34, which had subsequently recovered, most of the GP’s felt they would have arranged to repeat the blood test in the first instance.” Source location 2015-0121-Response-by-Davyhulme-Medical-Centre
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations