Recipient

Derriford Hospital

First report 5 Dec 2013•Latest report 21 Sep 2020

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Multi-service care provider. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 6
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

21 Sep2020
Plymouth, Torbay and South Devon
Concerns raised2
1. Failure to fully appreciate and understand patients' underlying medical conditions before anaesthesia
2. Unavailability of full patient medical records before anaesthesia
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

Paul Vincent Reynolds · 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

Paul Vincent Reynolds underwent finger surgery under general anaesthetic after presenting to hospital with a swollen hand and a necrotic finger. He suffered a loss of blood pressure and a hypoxic period following the anaesthetic, and died from the hypoxic event on 31 December 2019. The concerns identified included the unavailability of his full hospital notes and an incomplete understanding of his underlying medical condition, leading to an inappropriate choice of monitoring and anaesthetic.

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 Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to fully appreciate and understand patients' underlying medical conditions before anaesthesia
Wider context from the report
“A Root Cause Analysis by an Independent Anaesthetist found:- Root Cause There was an incomplete appreciation and understanding of the patients underlying medical condition which led to an incorrect choice of monitoring and anaesthetic. The unavailability of the full patient record meant that the anaesthetic team were reliant on the patient history and the admission clerking record to assess the patient. Lessons Learned The full set of patient medical records must be obtained as soon as possible following admission particularly when a procedure involving anaesthesia is planned. The safe conduct of anaesthesia is reliant on being fully conversant with the patient's pre-existing medical conditions and patients should not be anaesthetised before the medical records have been obtained and reviewed. Recommendations 1. Medical records must be obtained as soon as possible following admission to the ward by a ward clerk. 2. The ward administration team must check daily that all medical records are available or have been requested and an expected time-frame for the medical records to be available. 3. If adequate patient records are not available, the patient should not go to theatre unless it is a life or limb threatening emergency. ”
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 Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of full patient medical records before anaesthesia
Wider context from the report
“A Root Cause Analysis by an Independent Anaesthetist found:- Root Cause There was an incomplete appreciation and understanding of the patients underlying medical condition which led to an incorrect choice of monitoring and anaesthetic. The unavailability of the full patient record meant that the anaesthetic team were reliant on the patient history and the admission clerking record to assess the patient. Lessons Learned The full set of patient medical records must be obtained as soon as possible following admission particularly when a procedure involving anaesthesia is planned. The safe conduct of anaesthesia is reliant on being fully conversant with the patient's pre-existing medical conditions and patients should not be anaesthetised before the medical records have been obtained and reviewed. Recommendations 1. Medical records must be obtained as soon as possible following admission to the ward by a ward clerk. 2. The ward administration team must check daily that all medical records are available or have been requested and an expected time-frame for the medical records to be available. 3. If adequate patient records are not available, the patient should not go to theatre unless it is a life or limb threatening emergency. ”
Open source report
22 Aug2019
Plymouth, Torbay and South Devon
Concerns raised1
1. Lack of assurance that recommendations are being followed
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

Euan David Brinley ELLIS · 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

Euan David Brinley ELLIS, who had Marfan’s Syndrome and cardiac vulnerability, attended hospital with chest pains on 19 November 2017 and his GP the following day. He suffered a fatal haemopericardium at home on 23 November 2017. Concerns included limited access to his medical records and assurance that recommendations from a multidisciplinary investigation were being followed.

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 Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of assurance that recommendations are being followed
Wider context from the report
“At the Inquest the Coroner received evidence from ████████ who referred to a multi disciplinary investigation which contained recommendations. The Coroner is concerned to be assured that the recommendations are being followed. ”
Open source report
18 Apr2019
Plymouth, Torbay and South Devon
Concerns raised1
1. Failure to provide confirmation of fulfilment of Root Cause Analysis recommendations
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

Roger Albert NEAVES · 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

Roger Albert Neaves fell in his bedroom on 16 October 2018, fractured his left femur, was taken to hospital, deteriorated and died on 18 October 2018. The Coroner was concerned to receive confirmation that recommendations from the Hospital Trust’s Root Cause Analysis had been fulfilled.

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 Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide confirmation of fulfilment of Root Cause Analysis recommendations
Wider context from the report
“The Coroner received evidence from ████████ the author of a Root Cause Analysis conducted by the Hospital Trust following Mr Neaves’s death. That Root Cause Analysis made various recommendations which required action by the Hospital Trust. The Coroner is concerned to receive confirmation that the recommendations have been fulfilled. ”
Open source report
3 Apr2019
Plymouth, Torbay and South Devon
Concerns raised4
1. Insufficient radiology clinician staffing
2. Failure to transfer prescribed medication to the community hospital
3. Failure to transfer complete discharge documentation to the community hospital
1. Lack of medical cover at the community hospital during out-of-hours admissions
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

Terence Douglas Thornton · Prevention of Future Deaths report

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

Report summary

Terence Douglas Thornton was admitted to hospital after a fall in which he struck his head, while receiving warfarin. A subtle subdural haemorrhage was missed on the initial CT scan; after discharge and administration of enoxaparin, the haemorrhage expanded catastrophically and he died on 19 September 2017. The concerns included radiology staffing shortages and work pressures, with a consequent risk of similar fatalities.

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 Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Insufficient radiology clinician staffing
Wider context from the report
“(1) At the Inquest I heard evidence from ████████ Clinical Director for Radiology at Derriford Hospital. He told me that, currently, there are 44 radiologists working within the Trust. He told me that he believed there was a need for up to a further 16 clinicians across a range of specialities. (2) I also heard evidence from ████████ who felt that work pressures may have caused or contributed to the error that occurred in this instance. (3) It is not the first time that shortages of radiology clinicians has been brought to my attention at Inquest. I am aware that there are difficulties in this regard nationally but I am concerned that the problems in Derriford appear to be worsening with the consequent risk that similar fatalities may occur in the future. In the circumstances, it is my duty to report this situation to you so that you may consider what action needs to be taken to address the situation. ”
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 Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to transfer prescribed medication to the community hospital
Wider context from the report
“BRIEF SUMMARY OF MATTERS OF CONCERN (1) During the course of the Inquest, I heard evidence from ████████ at Liskeard community hospital. She gave evidence that when Mr Thornton was admitted from Derriford, he arrived without an E-discharge, a copy of his prescription chart or his prescribed medication. As he was admitted during a Sunday evening where there was no medical cover in the hospital, this created very real difficulties. The out of hours service had to be contacted for a doctor to attend. In the event, that Doctor refused to prescribe blood thinning medication and Mr Thornton did not receive any for nearly 24 hours notwithstanding his known history of DVTs. ████████ told me that this “happens frequently.” (2) I also heard from Doctor Sant. He works in Liskeard hospital on Mondays and Fridays. On Mondays, he deals with patients who have had been admitted from Derriford over the course of the weekend. He told me in evidence that his “guess” was that between 5 – 10% of patients do not arrive with the correct paperwork or medication. He agreed with my suggestion that if this was allowed to continue it would inevitably result in the future with a patient suffering harm. (3) I would be grateful if you would consider the process for discharging patients from Derriford to Liskeard community hospital particularly where that discharge occurs out of hours, on a Friday (before the weekend) or over the course of a weekend. You may feel that there is a need to ensure the process is more robust and that patients are not discharged without any of the e-discharge form, a copy of the prescription chart and any prescribed medication. You may feel that it would be sensible to audit compliance with these requirements to ensure that an efficient and effective discharge to a community hospital takes place. ”
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 Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to transfer complete discharge documentation to the community hospital
Wider context from the report
“BRIEF SUMMARY OF MATTERS OF CONCERN (1) During the course of the Inquest, I heard evidence from ████████ at Liskeard community hospital. She gave evidence that when Mr Thornton was admitted from Derriford, he arrived without an E-discharge, a copy of his prescription chart or his prescribed medication. As he was admitted during a Sunday evening where there was no medical cover in the hospital, this created very real difficulties. The out of hours service had to be contacted for a doctor to attend. In the event, that Doctor refused to prescribe blood thinning medication and Mr Thornton did not receive any for nearly 24 hours notwithstanding his known history of DVTs. ████████ told me that this “happens frequently.” (2) I also heard from Doctor Sant. He works in Liskeard hospital on Mondays and Fridays. On Mondays, he deals with patients who have had been admitted from Derriford over the course of the weekend. He told me in evidence that his “guess” was that between 5 – 10% of patients do not arrive with the correct paperwork or medication. He agreed with my suggestion that if this was allowed to continue it would inevitably result in the future with a patient suffering harm. (3) I would be grateful if you would consider the process for discharging patients from Derriford to Liskeard community hospital particularly where that discharge occurs out of hours, on a Friday (before the weekend) or over the course of a weekend. You may feel that there is a need to ensure the process is more robust and that patients are not discharged without any of the e-discharge form, a copy of the prescription chart and any prescribed medication. You may feel that it would be sensible to audit compliance with these requirements to ensure that an efficient and effective discharge to a community hospital takes place. ”
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 Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of medical cover at the community hospital during out-of-hours admissions
Wider context from the report
“BRIEF SUMMARY OF MATTERS OF CONCERN (1) During the course of the Inquest, I heard evidence from ████████ at Liskeard community hospital. She gave evidence that when Mr Thornton was admitted from Derriford, he arrived without an E-discharge, a copy of his prescription chart or his prescribed medication. As he was admitted during a Sunday evening where there was no medical cover in the hospital, this created very real difficulties. The out of hours service had to be contacted for a doctor to attend. In the event, that Doctor refused to prescribe blood thinning medication and Mr Thornton did not receive any for nearly 24 hours notwithstanding his known history of DVTs. ████████ told me that this “happens frequently.” (2) I also heard from Doctor Sant. He works in Liskeard hospital on Mondays and Fridays. On Mondays, he deals with patients who have had been admitted from Derriford over the course of the weekend. He told me in evidence that his “guess” was that between 5 – 10% of patients do not arrive with the correct paperwork or medication. He agreed with my suggestion that if this was allowed to continue it would inevitably result in the future with a patient suffering harm. (3) I would be grateful if you would consider the process for discharging patients from Derriford to Liskeard community hospital particularly where that discharge occurs out of hours, on a Friday (before the weekend) or over the course of a weekend. You may feel that there is a need to ensure the process is more robust and that patients are not discharged without any of the e-discharge form, a copy of the prescription chart and any prescribed medication. You may feel that it would be sensible to audit compliance with these requirements to ensure that an efficient and effective discharge to a community hospital takes place. ”
Open source report
4 Jan2016
Plymouth, Torbay and South Devon
Concerns raised4
1. Failure to document headache assessment and clinical reasoning
2. Inadequate and incomplete recording of clinical events
3. Failure to apply updated Neurology referral criteria for reported weakness
1. Delays in processing incoming clinical consultation records
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 Alexander Burchell · 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 Alexander Burchell had a brain tumour and developed progressive seizures after transfer for neurosurgical treatment; the post-mortem medical cause of death was brain swelling and infarction associated with glioblastoma. Concerns included incomplete records of the seizures and inadequate documentation and assessment of earlier headaches and weakness, including delays in processing prior medical records and uncertainty about referral 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 Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to document headache assessment and clinical reasoning
Wider context from the report
“(1) There is nothing in the records to explain how ████████ came to the view that Thomas was suffering from stress related headaches. Further, there is nothing in the notes to confirm whether or not he asked Thomas any questions at all about his headaches. In his evidence, ████████ had to accept that it was possible he did not do so. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inadequate and incomplete recording of clinical events
Wider context from the report
“(1) Inadequate and incomplete record keeping. This is in respect of both medical and nursing records. In particular, the seizure chart stated late and finished early. It is far from an accurate or complete record of what happened to Thomas. (2) In a neurosurgical unit I understand there will be patients having seizures on a regular basis. I further understand that it is extremely rare for those seizures to progress as befell Thomas and then prove resistant to treatment. Where a patient does develop seizures, however, I consider that there should be a far more robust and complete record of the relevant events. ”
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 Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to apply updated Neurology referral criteria for reported weakness
Wider context from the report
“(3) In his preparation for a subsequent significant events meeting, ████████ identified that the basis for referring a patient to Neurology had changed. He had previously been under the impression that he needed not only to have a complaint of weakness but also objectively to identify and confirm this weakness. He accepted that the guidance had changed so that a complaint of weakness alone was sufficient to warrant referral. ”
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 Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in processing incoming clinical consultation records
Wider context from the report
“(2) ████████ also accepted in evidence that had he seen the notes and records from the Exeter consultation (which red flagged the headache entry) he would have treated Thomas differently and perhaps taken his concerns more seriously.. It was not completely clear when the records from the Exeter consultation arrived at the Borchardt practice. It was, however, before Thomas’ appointment with ████████ and there may have been several days (perhaps as much as a week) between the arrival of the notes and their “processing” by administrative staff. Such a delay is undesirable. ”
Open source report
5 Dec2013
Plymouth, Torbay and South Devon
Concerns raised3
1. Failure of clinicians to access alerts or allergy information recorded in other hospitals
2. Failure of radiographers to access alerts or allergy information across hospital computer programmes
3. Insufficient nursing staff awareness of chlorhexidine anaphylaxis risk and presence in skin-sterilising solutions
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

Desmond Roy Statton · 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

Desmond Roy Statton died after suffering a severe allergic reaction shortly after contrast medium was administered for a CT scan. The report raises concerns that radiographers and clinicians could not access allergy and alert information held on other hospital computer systems, and that nursing staff were not sufficiently aware of the risks associated with chlorhexidine.

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 Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of clinicians to access alerts or allergy information recorded in other hospitals
Wider context from the report
“2. Derriford is a tertiary hospital and accepts admissions from other hospitals elsewhere in the South West. Clinicians in Derriford are not able to access information relating to alerts or allergies recorded on the computer programmes in other hospitals. ”
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 Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of radiographers to access alerts or allergy information across hospital computer programmes
Wider context from the report
“1. Radiographers are not able to access information concerning alerts or allergies contained on different computer programmes elsewhere in the Hospital. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derriford Hospital; that does not assign responsibility.
PFD Monitor interpretation
Insufficient nursing staff awareness of chlorhexidine anaphylaxis risk and presence in skin-sterilising solutions
Wider context from the report
“3. Nursing staff are not sufficiently aware that Chlorhexidine is a growing cause of anaphylactic reactions and that it is contained within solutions used to sterilise the skin (and elsewhere.) ”
Open source report

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 fully appreciate and understand patients' underlying medical conditions before anaesthesia

Unavailability of full patient medical records before anaesthesia

Concerns raised1

Lack of assurance that recommendations are being followed

Concerns raised1

Failure to provide confirmation of fulfilment of Root Cause Analysis recommendations

Concerns raised4

Insufficient radiology clinician staffing

Failure to transfer prescribed medication to the community hospital

Failure to transfer complete discharge documentation to the community hospital

Lack of medical cover at the community hospital during out-of-hours admissions

Concerns raised4

Failure to document headache assessment and clinical reasoning

Inadequate and incomplete recording of clinical events

Failure to apply updated Neurology referral criteria for reported weakness

Delays in processing incoming clinical consultation records

Concerns raised3

Failure of clinicians to access alerts or allergy information recorded in other hospitals

Failure of radiographers to access alerts or allergy information across hospital computer programmes

Insufficient nursing staff awareness of chlorhexidine anaphylaxis risk and presence in skin-sterilising solutions