Concerns raised 5 Failure to follow up Nerve Centre system escalation triggers View source Lack of clear direction from the attending doctor following a fall View source Lack of a clear plan for the frequency and duration of neurological observations following a fall View source Failure to complete inpatient post-fall reviews View source Failure to properly complete Nerve Centre system escalation records 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
Dennis Keith Price · 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
Dennis Keith Price, a 71-year-old man, died on 28 October 2024 after falling while making his way unescorted to the toilet during a hospital admission. He suffered a subdural haemorrhage after the fall, and concerns included incomplete post-fall review, unclear neurological-observation instructions, and delays or failures in responding to Nerve Centre alerts.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up Nerve Centre system escalation triggers
Wider context from the report “3. The efficiency of the Nerve Centre system escalations in that any triggers must be followed up and properly completed on the system for the nerve centre system to be fully effective.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear direction from the attending doctor following a fall
Wider context from the report “2. No clear plan for frequency of neurological observations and duration of the same and associated lack of clear direction from the attending Doctor following a fall .
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear plan for the frequency and duration of neurological observations following a fall
Wider context from the report “2. No clear plan for frequency of neurological observations and duration of the same and associated lack of clear direction from the attending Doctor following a fall.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete inpatient post-fall reviews
Wider context from the report “1. Failure to properly complete the inpatient post fall review .
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly complete Nerve Centre system escalation records
Wider context from the report “3. The efficiency of the Nerve Centre system escalations in that any triggers must be followed up and properly completed on the system for the nerve centre system to be fully effective.
” 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 and reinforce multidisciplinary training on complete, contemporaneous clinical documentation, including post-fall records and neurological observations.
Verbatim wording from the response “The Trust recognises that training is fundamental in reinforcing the importance of complete, accurate and contemporaneous clinical documentation, and this remains a core component of all education delivered by the Patient Safety Team. In addition, targeted documentation training has been delivered by the Trust’s Solicitor/Legal Manager to Foundation Year 1 doctors on 11 September 2025, and to Preceptorship Nurses on 11 and 25 November 2025. This programme of education forms part of an ongoing initiative, with further lectures and seminars planned to ensure continued reinforcement of documentation standards across the organisation.” Source location 2026-0037 - Response from Doncaster Royal Infirmary
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 Reinforce Nerve Centre escalation procedures so triggers are actioned, followed up and fully documented, including the receiving clinician’s name and role.
Verbatim wording from the response “The Trust recognises the importance of the Nerve Centre system in supporting timely escalation and clinical decision-making and acknowledges the concern raised regarding the effectiveness of escalations where system triggers are not fully completed. Review of Mr Price’s care identified a documentation gap within Nerve Centre, specifically the absence of a recorded name confirming to whom the escalation was made, which limited assurance that the escalation process had been completed as intended. For the Nerve Centre system to function effectively, it is essential that all triggers are acted upon, followed up and fully documented, including clear identification of the clinician to whom concerns are escalated.” Source location 2026-0037 - Response from Doncaster Royal Infirmary
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 Embed requirements for attending doctors to document individualised post-fall neurological observation plans covering frequency, duration, review and escalation criteria.
Verbatim wording from the response “The Trust acknowledges the concern regarding the absence of consistently documented medical direction for the frequency and duration of neurological observations following Mr Price’s fall. While the Patient Falls Prevention and Management Policy (PAT/PS 11) provides guidance on post-fall management, learning has identified the need for clearer, explicit documentation by the attending doctor to ensure that neurological observation requirements, review arrangements and escalation plans are clearly defined and understood by the multidisciplinary team. As part of ongoing improvement, the Trust is reinforcing the expectation that a clear, individualised post-fall monitoring plan is documented following every fall, supported through strengthened documentation standards, targeted multidisciplinary training and continued emphasis on completion of the Inpatient Post-Fall Review.” Source location 2026-0037 - Response from Doncaster Royal Infirmary
Open published response
Concerns raised 4 Failure to keep adequate records of falls care View source Failure to maintain adequate discharge handover information View source Failure to keep adequate wound management records View source Failure to use aseptic techniques and maintain cleanliness during wound management 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
Walter Colin HORTON · 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
Walter Colin HORTON, an 88-year-old male, died in a nursing home on 10 January 2025. The recorded causes included sepsis and an advanced sacral pressure sore, with ischaemic heart disease also noted. Concerns included poor record keeping and failures to understand or follow aseptic techniques and cleanliness when managing wounds, increasing the risk of infection.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep adequate records of falls care
Wider context from the report “(1) Poor record keeping in regard to key areas of care namely falls and wound management
and handover information on discharge
(2) A failure to understand or to follow use of aseptic techniques and cleanliness when
managing wounds thus increasing the risk of infection.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate discharge handover information
Wider context from the report “(1) Poor record keeping in regard to key areas of care namely falls and wound management
and handover information on discharge
(2) A failure to understand or to follow use of aseptic techniques and cleanliness when
managing wounds thus increasing the risk of infection.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep adequate wound management records
Wider context from the report “(1) Poor record keeping in regard to key areas of care namely falls and wound management
and handover information on discharge
(2) A failure to understand or to follow use of aseptic techniques and cleanliness when
managing wounds thus increasing the risk of infection.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use aseptic techniques and maintain cleanliness during wound management
Wider context from the report “(1) Poor record keeping in regard to key areas of care namely falls and wound management
and handover information on discharge
(2) A failure to understand or to follow use of aseptic techniques and cleanliness when
managing wounds thus increasing the risk of infection.
” 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 Operate a Trust-wide action group to improve discharge processes and report to the Patient Safety Review Group.
Verbatim wording from the response “• A Trust-wide action group is in place to drive quality improvement in discharge processes, reporting to the Patient Safety Review Group.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
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 Operate a Trust-wide action group to drive discharge-process quality improvement and report to the Patient Safety Review Group.
Verbatim wording from the response “• A Trust-wide action group is in place to drive quality improvement in discharge processes, reporting to the Patient Safety Review Group.” Source location Response from Doncaster & Bassetlaw 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 There is no record or evidence that the patient experienced a fall during admission.
Verbatim wording from the response “• There is no record or evidence of Mr Horton experiencing a fall during his admission.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
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 There was no evidence of an aseptic technique breach during wound care.
Verbatim wording from the response “• A detailed review found no evidence of breach in aseptic technique during wound care.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
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 Trust disputes that wound care involved a breach of aseptic technique, stating that review found no evidence of one.
Verbatim wording from the response “4. Aseptic Technique and Wound Cleanliness” Source location Response from Doncaster & Bassetlaw 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 Trust disputes that Mr Horton experienced a fall during admission, stating that no record or evidence of a fall exists.
Verbatim wording from the response “1. Record Keeping - Falls” Source location Response from Doncaster & Bassetlaw NHS Foundation Trust
Open published response
Concerns raised 3 Failure of systems and documentation to identify whether requested investigations had been performed View source Failure to control and record cancellation of tests and actions by temporary or unauthorised users View source Failure to maintain accurate medical records and communicate information needed for urgent tests View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lee James STAMMERS · 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
Lee Stammers attended Doncaster Royal Infirmary on 10 February 2025 with chest pain, shortness of breath and nausea, suffered a cardiorespiratory arrest later that day, and was pronounced deceased at 20:00 hours. The report identified missed opportunities to detect myocardial ischaemia, including incomplete or unreported electrocardiography and blood tests not being performed. Concerns also included poor documentation, communication and systems for tracking investigations, and the ability of unidentified staff to cancel tests without rationale or accountability.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of systems and documentation to identify whether requested investigations had been performed
Wider context from the report “(1) Poor documentation, Communication, and systems–
There were no clear communication, documentation, or systems in place, to identify if investigations had been performed as requested. For example, the medical records indicated blood had been obtained and collected by the laboratory and the result was awaited. When blood had not been obtained.
Inaccurate information in the medical records and poor communication, led to a failure of urgent tests being undertaken. A comparable situation occurred, in relation to confusion regarding the performance of the electrocardiogram.
Poor communication, documentation, and systems allowed tests/actions to be cancelled by student nurses, temporary staff and locum clinicians, who can also access the system and cancel tests without any rationale, accountability or identifying themselves in the records. These individuals were referred to as “unknown” at the inquest and have not been identified.
Finally, there was clear and consistent evidence of poor documentation throughout the medical records, from admission to the emergency department continuing through to the resuscitation attempts.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to control and record cancellation of tests and actions by temporary or unauthorised users
Wider context from the report “(1) Poor documentation, Communication, and systems–
There were no clear communication, documentation, or systems in place, to identify if investigations had been performed as requested. For example, the medical records indicated blood had been obtained and collected by the laboratory and the result was awaited. When blood had not been obtained.
Inaccurate information in the medical records and poor communication, led to a failure of urgent tests being undertaken. A comparable situation occurred, in relation to confusion regarding the performance of the electrocardiogram.
Poor communication, documentation, and systems allowed tests/actions to be cancelled by student nurses, temporary staff and locum clinicians , who can also access the system and cancel tests without any rationale, accountability or identifying themselves in the records . These individuals were referred to as “unknown” at the inquest and have not been identified.
Finally, there was clear and consistent evidence of poor documentation throughout the medical records, from admission to the emergency department continuing through to the resuscitation attempts.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate medical records and communicate information needed for urgent tests
Wider context from the report “(1) Poor documentation, Communication, and systems–
There were no clear communication, documentation, or systems in place, to identify if investigations had been performed as requested. For example, the medical records indicated blood had been obtained and collected by the laboratory and the result was awaited. When blood had not been obtained.
Inaccurate information in the medical records and poor communication, led to a failure of urgent tests being undertaken. A comparable situation occurred, in relation to confusion regarding the performance of the electrocardiogram.
Poor communication, documentation, and systems allowed tests/actions to be cancelled by student nurses, temporary staff and locum clinicians, who can also access the system and cancel tests without any rationale, accountability or identifying themselves in the records. These individuals were referred to as “unknown” at the inquest and have not been identified.
Finally, there was clear and consistent evidence of poor documentation throughout the medical records , from admission to the emergency department continuing through to the resuscitation attempts.
” 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 Introduce a local Emergency Department quality-improvement initiative focused on communication and contemporaneous documentation.
Verbatim wording from the response “Safety Recommendation 4 – The ED to introduce a local quality improvement initiative focusing on enhancing communication and contemporaneous documentation in both emergency and non-emergency situations.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Implement the identified communication and documentation immediate safety actions in the Emergency Department under senior-doctor oversight.
Verbatim wording from the response “Mr Stammers’ case was formally presented to the Learning from Patient Safety Events (LFPSE) Panel with the declaration of a Patient Safety Incident Investigation (PSII). During this meeting, Immediate Safety Actions were identified and shared with the relevant division to ensure prompt implementation.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Restrict Symphony user permissions for student nurses to prevent changes to prescribed care.
Verbatim wording from the response “Safety Recommendation 3 - Symphony user access to be reviewed and permissions changed to prevent user changes to prescribed care errors. Urgent & Emergency Care to consider how locum access can be strengthened to ensure traceability and an audit trail.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 and implement a chest-pain standing operating procedure defining required clinical assessment and investigations in the Emergency Department.
Verbatim wording from the response “Safety Recommendation 2 - The ED should develop Standing Operating Procedure (SOP) to ensure standardised care within the ED when patients present with chest pain. This should include expectations of the clinical assessment and investigation required. Once implemented, this should be followed by education and training for all ED staff.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Require locum doctors to enter their full name and GMC number on first Symphony login to provide traceability and an audit trail.
Verbatim wording from the response “Safety Recommendation 3 - Symphony user access to be reviewed and permissions changed to prevent user changes to prescribed care errors. Urgent & Emergency Care to consider how locum access can be strengthened to ensure traceability and an audit trail.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
Open published response
18 Aug 2025 Emily · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Inaccurate and inadequate completion of fluid balance charts View source Nursing assessments failing to identify deteriorating patients View source Inadequate assessments of hydration status for ward patients View source Lack of clinical assessment before discharge home from the Emergency Department View source Lack of clinical assessment before referral for mental health assessment in Emergency Department patients View source Failure to escalate deteriorating patients for medical assessment 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
Emily · 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 died at Bassetlaw DGH on 6 May 2024 after developing unrecognised dehydration, acute kidney injury, ileus and sub-acute small bowel obstruction following bowel surgery for Crohn’s disease. She experienced vomiting, aspiration pneumonitis and cardiac arrest, with the report identifying concerns about inadequate hydration assessment, fluid-balance recording, recognition of deterioration, clinical assessment and escalation, and response to family concerns. The report also raises concerns about clinical assessment in the Emergency Department before mental health referral or discharge home.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and inadequate completion of fluid balance charts
Wider context from the report “1. That patients on the wards at Bassetlaw DGH will have inadequate assessments of hydration status, and have inaccurate and inadequate completion of fluid balance charts
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Nursing assessments failing to identify deteriorating patients
Wider context from the report “2. That nursing assessments , particularly in very vulnerable patients, will not identify a deteriorating patient , thus preventing necessary escalation for medical assessment
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate assessments of hydration status for ward patients
Wider context from the report “1. That patients on the wards at Bassetlaw DGH will have inadequate assessments of hydration status , and have inaccurate and inadequate completion of fluid balance charts
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical assessment before discharge home from the Emergency Department
Wider context from the report “3. That there continues to be a risk that no clinical assessment will be undertaken, in patients attending the Emergency Department at Bassetlaw DGH, prior to referral for a mental health assessment , and that there continues to be a risk that no clinical assessment will occur in Emergency Department prior to a patients discharge 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical assessment before referral for mental health assessment in Emergency Department patients
Wider context from the report “3. That there continues to be a risk that no clinical assessment will be undertaken, in patients attending the Emergency Department at Bassetlaw DGH, prior to referral for a mental health assessment , and that there continues to be a risk that no clinical assessment will occur in Emergency Department prior to a patients discharge 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate deteriorating patients for medical assessment
Wider context from the report “2. That nursing assessments, particularly in very vulnerable patients, will not identify a deteriorating patient, thus preventing necessary escalation for medical assessment
” 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 Conduct weekly fluid-balance audits with monthly matron oversight and ward-level action plans for non-compliance.
Verbatim wording from the response “• Use of Tendable, the Trust’s audit and quality improvement application, enabling weekly audits and monthly oversight by the Matron. Non-compliance triggers ward-level action plans.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Host a multidisciplinary Gastroenterology Masterclass addressing comprehensive nutrition and hydration assessment and fluid-intake monitoring.
Verbatim wording from the response “Additionally, the Division of Medicine are hosting a Gastroenterology Masterclass on 7 October 2025, focusing on multi-disciplinary training. A key component was the importance of comprehensive nutrition and hydration assessments for patients with Inflammatory Bowel Disease (IBD), including accurate fluid input/output monitoring.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 AKI Care Bundle across the Trust in February 2026.
Verbatim wording from the response “• Implementation of an Acute Kidney Injury (AKI) Care Bundle within the electronic patient record system in pilot areas. This includes prompts for fluid balance chart initiation and completion. Early evaluation indicates improved monitoring, with full Trust-wide rollout planned for February 2026.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Deliver ongoing education and training on fluid balance and hydration assessment through Medicine and Quality Improvement teams.
Verbatim wording from the response “• Ongoing education and training initiatives led by the Division of Medicine in collaboration with the Quality Improvement team.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Communicate the requirement for medical review before Emergency Department referral to mental health services.
Verbatim wording from the response “████████ Divisional Director, has formally communicated via email to all Emergency Department (ED) medical staff the requirement that all patients attending the ED must undergo a medical review prior to any referral to mental health services.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Audit compliance monthly with medical review before Emergency Department referral to mental health services and report results through governance.
Verbatim wording from the response “This process is subject to monthly audit, and the most recent audit demonstrated 100% compliance, with all patients referred to mental health services having received a documented medical review. This audit is part of an ongoing quality assurance initiative and is reported through the Audit and Effectiveness Forum to ensure sustained oversight and continuous improvement.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Transition to electronic fluid-balance charting to improve accuracy and provide real-time oversight.
Verbatim wording from the response “• Transition to electronic fluid balance charting, enhancing accuracy and enabling real-time oversight.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Launch and embed Trust-wide Safety Huddles at BDGH for real-time identification and escalation of safety concerns.
Verbatim wording from the response “• Safety Huddles have been launched Trust-wide and embedded at BDGH. These evidence-based initiatives support real-time identification and escalation of safety concerns. For example, a recent huddle identified a patient declining all oral intake, prompting immediate clinical review.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Strengthen verbal handovers during shift changes to support identification and escalation of safety concerns.
Verbatim wording from the response “• Verbal handover processes during shift changes have been strengthened.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Implement the AKI Care Bundle, including electronic prompts for fluid-balance charting, in pilot areas.
Verbatim wording from the response “• Implementation of an Acute Kidney Injury (AKI) Care Bundle within the electronic patient record system in pilot areas. This includes prompts for fluid balance chart initiation and completion. Early evaluation indicates improved monitoring, with full Trust-wide rollout planned for February 2026.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
Open published response
Concerns raised 3 Failure to consider learning from incidents View source Failure to make critical clinical information available to and/or considered by spinal surgeons before surgery View source Failure to undertake a formal investigation of incidents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Bell · 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 Bell died at St John's Hospice Doncaster on 10 February 2025 after right upper lobe pneumonia contributed to by an infected spinal surgery wound, ischaemic heart disease and localised left renal carcinoma. The report raises concerns that critical renal tumour information was not available to or considered by the spinal surgeons before surgery, and that the incident was not formally investigated or subject to organisational learning for about eight months.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider learning from incidents
Wider context from the report “2. The issue in the previous paragraph came to light shortly after the spinal surgery in October 2024. However, no investigation of the incident was undertaken by the Trust. At the time of the inquest no Datix report had been submitted. The witnesses accepted at inquest that a Datix would have been good practice. I am concerned that some 8 months after the incident no formal investigation had taken place and no consideration of any learning had occurred .
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make critical clinical information available to and/or considered by spinal surgeons before surgery
Wider context from the report “1. Renal investigations were undertaken following a fast track cancer referral in September 2024. Investigations were undertaken and on 16 October 2024 a renal MDT reviewed CT scans and recommended that Mr Bell be considered for left nephrectomy to treat a renal tumour. Although the MDT note was apparently in the electronic records, the spinal surgeons were not aware of the renal findings at the time of the spinal surgery on 25 October 2024. Had they been aware, spinal surgery would not have been undertaken at this stage with the renal surgery being prioritised. I am concerned that critical clinical information was not available to and/or considered by, the spinal surgeons before the spinal surgery took 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a formal investigation of incidents
Wider context from the report “2. The issue in the previous paragraph came to light shortly after the spinal surgery in October 2024. However, no investigation of the incident was undertaken by the Trust. At the time of the inquest no Datix report had been submitted. The witnesses accepted at inquest that a Datix would have been good practice. I am concerned that some 8 months after the incident no formal investigation had taken place and no consideration of any learning had occurred.
” 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 Enhance incident reporting by medical staff through clinical governance meetings and patient safety events.
Verbatim wording from the response “While the patient safety culture within the Trust is strong, it is recognised that incident reporting for learning purposes is predominantly undertaken by nursing colleagues. Significant work is underway across the Trust – through clinical governance meetings and patient safety events – to enhance incident reporting by medical staff.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 timely pre-operative assessment and day-of-surgery review by the operating surgeon and anaesthetist, documenting any required change in clinical plan.
Verbatim wording from the response “Immediate safety actions agreed - all patients with a TCI (“to come ‘in date”) now have a clinically appropriate pre-operative assessment, within a reasonable timescale, and the patient is reviewed by both the operating surgeon and anaesthetist on the day of surgery to establish if there has been any deterioration/change that would necessitate a change in clinical plan. This is documented in the patient’s notes, team brief and operation notes.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Investigate the incident through the broader thematic analysis and draft the thematic review and associated actions for Executive Team presentation.
Verbatim wording from the response “I can confirm that a DATIX incident form was completed on 30 July 2025, and the investigation remains ongoing as part of a broader thematic analysis. A comprehensive thematic review and associated actions are currently being drafted for presentation to the Executive Team.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
Open published response
Concerns raised 1 Lack of a clear internal procedure for disseminating external radiology addendum reports to the treating clinical team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Khadija Kerri · 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
Khadija Kerri was admitted to hospital after an unwitnessed fall downstairs that caused a head laceration and multiple traumatic injuries. Two cervical fractures and a rib fracture were missed in the initial radiology report, and although the discrepancy was identified and communicated within 24 hours, the information was not acted on until 23 June 2024 because there was no clear internal process for disseminating addendum reports. The inquest concluded that she died primarily from heart disease, against a background of traumatic injuries and other co-morbidities.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear internal procedure for disseminating external radiology addendum reports to the treating clinical team
Wider context from the report “There is no clear internal policy/procedure within Doncaster Royal Infirmary for disseminating either an addendum report and/or the information contained within the addendum report from the external third party radiology service to the treating clinical team . If this is not addressed there is potential for similar delays and incorrect management of patient 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 Upload the approved failsafe communication protocol to the Trust intranet for staff access.
Verbatim wording from the response “Once fully approved and ratified, the protocol will be uploaded onto the Trust’s intranet within the Policies & Procedures section which is accessible by all staff. It is important to note this is a Trust-wide Policy which provides further enhancement to the safety of our patients on all hospital sites.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals 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 Audit failsafe notifications within three months of protocol implementation to verify appropriate communication and management.
Verbatim wording from the response “In accordance with the Trust’s approved policy procedure, the Failsafe protocol will be audited within 3 months of implementation to ensure all “Failsafe notifications” are communicated and managed appropriately.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals 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 Complete the review of the radiological findings communication protocol.
Verbatim wording from the response “I would like to take this opportunity of assuring you and Ms Kerri’s family that the Trust has undertaken a full review of the Failsafe Alert for Radiological Findings (Communication Protocol) PAT/T 38 v.5 and this is scheduled to be duly approved through the Local Clinical Governance processes by the 4 June 2025. Our Radiology department communicated with Everlight Radiology to ensure their full agreement with” Source location Response from Doncaster and Bassetlaw Teaching Hospitals 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 Obtain governance approval and ratification of the amended failsafe communication protocol.
Verbatim wording from the response “I would like to take this opportunity of assuring you and Ms Kerri’s family that the Trust has undertaken a full review of the Failsafe Alert for Radiological Findings (Communication Protocol) PAT/T 38 v.5 and this is scheduled to be duly approved through the Local Clinical Governance processes by the 4 June 2025. Our Radiology department communicated with Everlight Radiology to ensure their full agreement with” Source location Response from Doncaster and Bassetlaw Teaching Hospitals 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 referrer remains responsible for reading and acting on radiology reports; the failsafe protocol does not replace that clinical responsibility.
Verbatim wording from the response “Whilst it is recognised that this revision is essential to ensure patient safety, it is acknowledged that the safety net contained within the protocol does not replace the Referrer’s responsibility to read and act upon radiology reports. This is in line with national guidance “Recommendations on Alerts and Notification of Imaging Reports”, published by the Academy of Medical Royal Colleges October 2022.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Open published response
18 Feb 2025 Mrs Marina May Raisbeck · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Lack of a system for monitoring clinical parameters of urgent surgical patients awaiting transfer View source Lack of a system for prioritisation of urgent surgical patients awaiting transfer View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Marina May Raisbeck · 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
Mrs Marina May Raisbeck died on 7 November 2023 at Doncaster Royal Infirmary from sepsis secondary to a perianal abscess. The report identifies concerns about the lack of systems to prioritise urgent surgical patients awaiting transfer and to monitor their clinical parameters at Bassetlaw District General Hospital.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for monitoring clinical parameters of urgent surgical patients awaiting transfer
Wider context from the report “2. The lack of a system for monitoring clinical parameters of urgent surgical patients awaiting transfer to DRI from the Emergency Department at Bassetlaw District General 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for prioritisation of urgent surgical patients awaiting transfer
Wider context from the report “1. The lack of a system for prioritisation of urgent surgical patients awaiting transfer to DRI from the Emergency Department at Bassetlaw District General Hospital
” 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 Conduct daily face-to-face clinical assessments of surgical patients awaiting transfer to prioritise transfers and monitor blood tests.
Verbatim wording from the response “To enhance this standard, the Trust has immediately implemented a new initiative in Bassetlaw Hospital whereby every morning a Surgical Advanced Clinical Practitioner will undertake a face to face assessment of all surgical patients awaiting transfer to Doncaster Royal Infirmary in order to prioritise transfer. This assessment will include a full clinical review including monitoring blood tests.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Discuss implementation of the tracking system with wider specialties for surgical patients.
Verbatim wording from the response “Meanwhile, further discussions with our wider specialties are commencing to implement the tracker for our surgical patients.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Tailor the tracking system to orthopaedic standards and complete its implementation.
Verbatim wording from the response “Discussions are nearing completion with our orthopaedic team to tailor the tracking system to reflect their standards of care and implementation is expected to be complete within 3-6 months.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 and roll out a digital tracking system monitoring referred patients’ physiology, sepsis parameters and observations for clinical-team oversight and prioritisation.
Verbatim wording from the response “The Trust has successfully developed a tracking system which provides oversight to the host and receiving clinical teams and monitors the patient’s physiology parameters (including sepsis) and observations. It also enables clinical teams to prioritise patient care. This digital programme of work has already been rolled out in Acute Medicine and Paediatrics on both Bassetlaw and Doncaster Hospital sites to allow them to easily view all patients in the ED that have been referred to them.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
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 Implementation of surgical patient tracking is constrained by competing digital priorities and limited resources and capacity.
Verbatim wording from the response “Discussions are nearing completion with our orthopaedic team to tailor the tracking system to reflect their standards of care and implementation is expected to be complete within 3-6 months.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals
Open published response
20 Jul 2022 Jade Michelle Hart · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Failure to obtain timely written accounts and interviews from key staff in serious incident investigations View source Failure to include and properly weight family evidence in serious incident investigations View source Failure to disclose a critical commissioned expert report to relevant oversight bodies View source Insufficient mentoring and out-of-hours senior support for newly appointed Obstetric Consultants View source Insufficient organisational learning from serious incident investigations View source Failure to properly consider commissioned expert evidence in serious incident investigations 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
Jade Michelle Hart · 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
Jade Michelle Hart died on 9 July 2018 after giving birth, following a uterine inversion caused by inappropriate management of the third stage of labour. She suffered massive uterine haemorrhage and multiple cardiac arrests, with delayed recognition and management of the bleeding, and the inquest concluded that her death was contributed to by neglect. The report raised concerns about the Trust’s serious incident investigation and insufficient support for newly appointed obstetric consultants.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain timely written accounts and interviews from key staff in serious incident investigations
Wider context from the report “1. The conduct of the Trust Serious Incident Investigation – there are outstanding concerns regarding the methodology, findings and conclusions in this case. The Investigation in my view was flawed in a number of serious ways as follows:
• It was undertaken without including, nor giving due weight to, the family evidence, in the analysis and conclusions of the report
• It was undertaken without any immediate written accounts taken of what had happened, and very limited and delayed interviews of key staff involved
• The Trust commissioned an expert to assist with the Investigation. This was provided by a well respected Royal College of Obstetrics and Gynaecology recommended expert, and was then ignored, simply because there were aspects of the expert report that the Trust did not accept.
All of these omissions in the Investigation process, led to serious omissions in the analysis, conclusions, recommendations and actions that followed in the report, in my view.
Also, the Trust, on the evidence of Dr ████████, Executive Medical Director, likely did not share with either the CCG or the CQC, the fact that they had received a detailed, but critical, expert report, that they had not included, nor referred to in the final Investigation report.
At the Hearing, there was no reflection on this latter issue by senior Trust staff, no acceptance that the inadequacies of the report had caused huge distress to the family, and more importantly insufficient learning.
If there is insufficient learning from a tragic and avoidable death such as this, what reassurance is there that there will be sufficient learning by the Trust in the future. In my view this poses a continuing risk of similar deaths occurring in the future if the Investigation process does not change.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include and properly weight family evidence in serious incident investigations
Wider context from the report “1. The conduct of the Trust Serious Incident Investigation – there are outstanding concerns regarding the methodology, findings and conclusions in this case. The Investigation in my view was flawed in a number of serious ways as follows:
• It was undertaken without including, nor giving due weight to, the family evidence, in the analysis and conclusions of the report
• It was undertaken without any immediate written accounts taken of what had happened, and very limited and delayed interviews of key staff involved
• The Trust commissioned an expert to assist with the Investigation. This was provided by a well respected Royal College of Obstetrics and Gynaecology recommended expert, and was then ignored, simply because there were aspects of the expert report that the Trust did not accept.
All of these omissions in the Investigation process, led to serious omissions in the analysis, conclusions, recommendations and actions that followed in the report, in my view.
Also, the Trust, on the evidence of Dr ████████, Executive Medical Director, likely did not share with either the CCG or the CQC, the fact that they had received a detailed, but critical, expert report, that they had not included, nor referred to in the final Investigation report.
At the Hearing, there was no reflection on this latter issue by senior Trust staff, no acceptance that the inadequacies of the report had caused huge distress to the family, and more importantly insufficient learning.
If there is insufficient learning from a tragic and avoidable death such as this, what reassurance is there that there will be sufficient learning by the Trust in the future. In my view this poses a continuing risk of similar deaths occurring in the future if the Investigation process does not change.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disclose a critical commissioned expert report to relevant oversight bodies
Wider context from the report “1. The conduct of the Trust Serious Incident Investigation – there are outstanding concerns regarding the methodology, findings and conclusions in this case. The Investigation in my view was flawed in a number of serious ways as follows:
• It was undertaken without including, nor giving due weight to, the family evidence, in the analysis and conclusions of the report
• It was undertaken without any immediate written accounts taken of what had happened, and very limited and delayed interviews of key staff involved
• The Trust commissioned an expert to assist with the Investigation. This was provided by a well respected Royal College of Obstetrics and Gynaecology recommended expert, and was then ignored, simply because there were aspects of the expert report that the Trust did not accept.
All of these omissions in the Investigation process, led to serious omissions in the analysis, conclusions, recommendations and actions that followed in the report, in my view.
Also, the Trust, on the evidence of Dr ████████, Executive Medical Director, likely did not share with either the CCG or the CQC, the fact that they had received a detailed, but critical, expert report , that they had not included, nor referred to in the final Investigation report .
At the Hearing, there was no reflection on this latter issue by senior Trust staff, no acceptance that the inadequacies of the report had caused huge distress to the family, and more importantly insufficient learning.
If there is insufficient learning from a tragic and avoidable death such as this, what reassurance is there that there will be sufficient learning by the Trust in the future. In my view this poses a continuing risk of similar deaths occurring in the future if the Investigation process does not change.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient mentoring and out-of-hours senior support for newly appointed Obstetric Consultants
Wider context from the report “2. Insufficient support for newly appointed Obstetric Consultants.
The Obstetric Consultant who was on call when Jade died, was newly appointed. She was dealing with an extremely complex and challenging situation, yet did not call for help at an early point, when Jade had had a prolonged cardiac arrest, following the uterine inversion. Whilst I accept that it is unrealistic to expect there to be a second Consultant on call every night or weekend to provide additional support, there does need to be a robust system of mentoring, and access to a senior consultant for prompt advice out of hours for at least one year post consultant appointment, and beyond, when serious emergencies such as this arise.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient organisational learning from serious incident investigations
Wider context from the report “1. The conduct of the Trust Serious Incident Investigation – there are outstanding concerns regarding the methodology, findings and conclusions in this case. The Investigation in my view was flawed in a number of serious ways as follows:
• It was undertaken without including, nor giving due weight to, the family evidence, in the analysis and conclusions of the report
• It was undertaken without any immediate written accounts taken of what had happened, and very limited and delayed interviews of key staff involved
• The Trust commissioned an expert to assist with the Investigation. This was provided by a well respected Royal College of Obstetrics and Gynaecology recommended expert, and was then ignored, simply because there were aspects of the expert report that the Trust did not accept.
All of these omissions in the Investigation process, led to serious omissions in the analysis, conclusions, recommendations and actions that followed in the report, in my view.
Also, the Trust, on the evidence of Dr ████████, Executive Medical Director, likely did not share with either the CCG or the CQC, the fact that they had received a detailed, but critical, expert report, that they had not included, nor referred to in the final Investigation report.
At the Hearing, there was no reflection on this latter issue by senior Trust staff , no acceptance that the inadequacies of the report had caused huge distress to the family, and more importantly insufficient learning .
If there is insufficient learning from a tragic and avoidable death such as this, what reassurance is there that there will be sufficient learning by the Trust in the future . In my view this poses a continuing risk of similar deaths occurring in the future if the Investigation process does not change.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly consider commissioned expert evidence in serious incident investigations
Wider context from the report “1. The conduct of the Trust Serious Incident Investigation – there are outstanding concerns regarding the methodology, findings and conclusions in this case. The Investigation in my view was flawed in a number of serious ways as follows:
• It was undertaken without including, nor giving due weight to, the family evidence, in the analysis and conclusions of the report
• It was undertaken without any immediate written accounts taken of what had happened, and very limited and delayed interviews of key staff involved
• The Trust commissioned an expert to assist with the Investigation. This was provided by a well respected Royal College of Obstetrics and Gynaecology recommended expert, and was then ignored, simply because there were aspects of the expert report that the Trust did not accept.
All of these omissions in the Investigation process, led to serious omissions in the analysis, conclusions, recommendations and actions that followed in the report, in my view.
Also, the Trust, on the evidence of Dr ████████, Executive Medical Director, likely did not share with either the CCG or the CQC, the fact that they had received a detailed, but critical, expert report, that they had not included, nor referred to in the final Investigation report.
At the Hearing, there was no reflection on this latter issue by senior Trust staff, no acceptance that the inadequacies of the report had caused huge distress to the family, and more importantly insufficient learning.
If there is insufficient learning from a tragic and avoidable death such as this, what reassurance is there that there will be sufficient learning by the Trust in the future. In my view this poses a continuing risk of similar deaths occurring in the future if the Investigation process does not change.
” 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 Operate cross-site consultant support, with an on-call obstetric consultant available at each maternity site and reciprocal advice and assistance.
Verbatim wording from the response “We accept that support for staff working at any level in the Trust will be required at times and this applies to the consultants we employ, at any stage after their appointment. We have two main receiving sites in the Trust and run two integrated services with linked, but separately staffed, maternity services at Doncaster Royal Infirmary and at Bassetlaw Hospital in Worksop. Each site has a consultant obstetrician available 24 hours a day. It is now embedded in obstetric practice that when a consultant on call on either site requires advice and support, they will contact the on-call consultant on the other site. This is normally to discuss a patient and is often for ethical advice over a hysterectomy in a young woman, as in this case.” Source location Response from NHS Doncaster and Bassetlaw Teaching Hospitals
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 Reference commissioned expert opinions in investigation reports and record reasons when an opinion is not reconciled with the evidence.
Verbatim wording from the response “As noted above, where an expert opinion is sought for the purposes of a Serious Investigation, it will now always be referenced within the report. Where the authors of the investigation report determine that the expert opinion provided cannot be reconciled with the evidence obtained through interviews and within statements, then the rationale for that determination will be included within the report.” Source location Response from NHS Doncaster and Bassetlaw Teaching Hospitals
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 Involve families directly in investigations and include their recollections and concerns, with supporting evidence, in reports.
Verbatim wording from the response “• we now involve families more directly and incorporate comments from families within investigation reports. A family’s recollection of events along with the clinicians’ recollection of events are both included to enable the author to draw reasonable conclusions based on the available evidence. Recollections may differ and reports will display these differences, balance any supportive evidence, and draw conclusions over the most likely description of events. There is expected to be evidence included to support the rationale for the conclusion.” Source location Response from NHS Doncaster and Bassetlaw Teaching Hospitals
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 a memory-capture document in DATIX alongside immediate interviews and written statements, and reinforce its use across teams.
Verbatim wording from the response “Furthermore, the Trust recognises how vital it is to document factual accounts of events at the earliest opportunity and that this should be done without delay. When an incident occurs within the organisation, this is immediately scoped which includes requesting a recollection of the event from all staff involved in the incident. To support this process, a memory capture document (please see attached) was developed and is accessible on the Trust’s Incident Reporting System (DATIX) for ease of access and is utilised in addition to undertaking initial interviews and obtaining factual accounts in the form of written statements.” Source location Response from NHS Doncaster and Bassetlaw Teaching Hospitals
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 external expert opinion was not relied upon because it conflicted with subsequently gathered evidence and was considered less informed than staff accounts.
Verbatim wording from the response “The Trust took the decision to seek an early external opinion for this case to ensure the investigation was both robust and comprehensive. We initially approached the Royal College of Obstetricians and Gynaecologists to ask them to conduct a review. They declined to do so, but were able to suggest the names of people who could assist and review the case, including ████████. We therefore approached ████████ who was provided with copies of the clinical records. We are mindful that clinical opinions can vary significantly, however the conclusion of ████████ report was at odds with the emerging evidence that we were subsequently gathering through the interviews and statements of” Source location Response from NHS Doncaster and Bassetlaw Teaching Hospitals
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 HSIB could not support the requested investigation because its northern branch had not yet been established and operations were limited to southern England.
Verbatim wording from the response “I can assure you that incidents of this kind are no longer investigated by the Trust and are now escalated to the Healthcare Safety Investigation Branch (HSIB) to carry out the investigation. As stated in the evidence provided in the inquest by ████████, Executive Medical Director, the Trust did approach HSIB shortly after the incident to request their involvement. However, they were unable to support us at that time, as their northern branch had not been established and they were only operating in the South of England.” Source location Response from NHS Doncaster and Bassetlaw Teaching Hospitals
Open published response
Concerns raised 5 Staff reluctance to accept confirmation bias and alter practices View source Failure to prioritise relevant staff for confirmation bias training View source Failure of all staff to consider and digest the Newsletters View source Failure of staff to understand confirmation bias View source Delayed completion of confirmation bias training by staff View source See 2 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
Clay Daniel Wanckiewicz · 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
Clay Daniel Wanckiewicz was born in very poor condition following failed forceps delivery and caesarean section complicated by a deeply impacted head, and died at 22 minutes of age from skull fractures. The principal concerns were confirmation bias, insufficiently open-minded assessment of the overall clinical picture, inadequate staff training and a continuing risk that similar situations could place mothers and babies at risk.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Staff reluctance to accept confirmation bias and alter practices
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a risk.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise relevant staff for confirmation bias training
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a risk.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of all staff to consider and digest the Newsletters
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a risk.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to understand confirmation bias
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a risk.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delayed completion of confirmation bias training by staff
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a risk.
” Open source report
28 Jul 2021 Jacob · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Lack of a system for recording child-related discussions in radiology meetings View source Absence of an alert and review system for ICE results across the paediatric team View source Lack of named or responsible consultant review before child discharge View source Low compliance with the paediatric sepsis screening tool View source Login issues for locum doctors working at the Trust View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 14
Action
Run radiology meetings as clinical multidisciplinary team meetings with named minute-taking, leave cover and filing of patient-specific information.
Stated completedThe respondent said that this action was complete when they made their response on 3 August 2021. View source
Action
Include recognition and management of the sick child, including sepsis screening, in Emergency Department junior-doctor induction.
Stated completedThe respondent said that this action was complete when they made their response on 3 August 2021. View source
Action
Develop and implement electronic paediatric observations, incorporating sepsis screening into Nervecentre after deployment.
Stated plannedThe respondent said that this action was planned when they made their response on 3 August 2021. View source
Action
Run weekly multidisciplinary paediatric simulation sessions across both sites, including paediatric sepsis topics.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021. View source
Action
Deliver recurring Emergency Department teaching sessions on sepsis recognition, management and use of the sepsis screening tool.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021. View source
Action
Develop and pilot a multidisciplinary sepsis audit tool covering the pathway from Emergency Department arrival.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021. View source
Action
Employ a Paediatric Clinical Educator for Emergency Department staff induction and sepsis-screening support.
Stated completedThe respondent said that this action was complete when they made their response on 3 August 2021. View source
Action
Incorporate sepsis screening into the Emergency Department Symphony system and train staff before implementation.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021. View source
Action
Complete weekly assurance audits of clinical records across acute areas, covering sepsis assessment and related discharge and communication safeguards.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021. View source
Action
Train paediatric consultants to review ICE results electronically and operate the electronic ICE system alongside a paper safety net.
Stated completedThe respondent said that this action was complete when they made their response on 3 August 2021. View source
Action
Disseminate sepsis-learning and screening-tool messages through staff memoranda, the monthly Matron Newsletter and Clinical Governance meeting records.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021. View source
Action
Review and approve the sepsis screening and action tool standard operating procedure through the specialty Clinical Governance meeting.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021. View source
Action
Monitor paediatric sepsis-screening compliance through quarterly audits and report results to clinical governance and quality committees.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021. View source
Action
Continue mandatory induction and multidisciplinary staff-development training on paediatric sepsis recognition, management and use of the screening tool.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021. View source See 11 more actions
×
AI-generated summary
Jacob · 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
Jacob died at eleven months from acute pyelonephritis, following earlier urinary tract sepsis and severe obstruction of both ureters. Investigations identifying the obstruction were not reviewed during his life, and the seriousness of a later infection was not recognised. The report identified concerns including low compliance with paediatric sepsis screening, lack of consultant review before discharge, and inadequate systems for reviewing investigation results.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for recording child-related discussions in radiology meetings
Wider context from the report “4. No current system for recording a discussion about a child, in the Radiology meetings (where important investigations are planned)
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of an alert and review system for ICE results across the paediatric team
Wider context from the report “3. No alert/review system for ICE results yet in place for all the Paediatric 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of named or responsible consultant review before child discharge
Wider context from the report “2. Lack of Named/Responsible Consultant review prior to a child’s 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Low compliance with the paediatric sepsis screening tool
Wider context from the report “1. Continuing low compliance with the Paediatric sepsis screening tool
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Login issues for locum doctors working at the Trust
Wider context from the report “5. The risk of continuing Login issues when Locum doctors are working at the Trust
” 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 Run radiology meetings as clinical multidisciplinary team meetings with named minute-taking, leave cover and filing of patient-specific information.
Verbatim wording from the response “As of 1 July 2021, radiology meetings are now clinical MDTs with meeting notes taken as by a named note taker and includes arrangements for cross cover for leave. The meeting notes are emailed to the relevant consultant, specific information related to individual patients are filed in their clinical notes.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 Include recognition and management of the sick child, including sepsis screening, in Emergency Department junior-doctor induction.
Verbatim wording from the response “• Inclusion of “Recognition & management of the sick child” which includes sepsis in junior doctors’ induction with reference to the sepsis screening and action tool. This training is aligned with the European Paediatric Advanced Life Support (EPALS) course and is delivered by the Paediatric Emergency Medicine Consultant.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 and implement electronic paediatric observations, incorporating sepsis screening into Nervecentre after deployment.
Verbatim wording from the response “• A working group has been developed to evolve from ‘paper-based’ physiological observation charts to electronic observations at both Doncaster and Bassetlaw. The current Paediatric Advanced Warning Score (PAWS) charts have been shared with Nervecentre for development on the platform and the paediatric team is working closely with Nervecentre. Due to a major incident at Doncaster Royal Infirmary which has resulted in the temporary relocation of children’s inpatient services the implementation date is December 2021 which is in line with services moving into modular wards. As advised by the implementation team once the e-observations are embedded in practice, sepsis screening will then be incorporated into Nervecentre. The paper version of the sepsis screening and action tool will remain in use until that time.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 Run weekly multidisciplinary paediatric simulation sessions across both sites, including paediatric sepsis topics.
Verbatim wording from the response “• Simulation sessions are run on both Doncaster and Bassetlaw sites weekly with one paediatric topic monthly, the last session on paediatric sepsis was in August. These are open for all members of the MDT they are not mandatory at present, however, ED are planning to make this a core competency for all the junior doctors during their training in ED.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 Deliver recurring Emergency Department teaching sessions on sepsis recognition, management and use of the sepsis screening tool.
Verbatim wording from the response “• Teaching sessions are delivered to junior and middle grade doctors twice in a 4 month period (junior doctors rotate every 4 months) with topics involving sepsis. This teaching session includes recognition and management of sepsis by using the sepsis screening and action tool. All junior doctors, nursing staff, advanced care practitioners (ACP), trainee ACPs and consultants can access these sessions through Microsoft Teams.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 and pilot a multidisciplinary sepsis audit tool covering the pathway from Emergency Department arrival.
Verbatim wording from the response “• A sepsis audit tool Task and Finish group with MDT input from both Paediatric and ED teams has been set up to review the audit tool for sepsis management, which will audit the pathway from the point of arrival in the Emergency Department. Due to the complexity of the different referral pathways this is a complex audit tool to develop, it is currently in the final stages of development, the aim is to pilot this in Q3. For Q2 the current audit tool will be used.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 Employ a Paediatric Clinical Educator for Emergency Department staff induction and sepsis-screening support.
Verbatim wording from the response “• Recruitment of a Paediatric Clinical Educator specifically for ED who works closely with the Paediatric Clinical Educators who support children’s services. The Clinical Educators support new staff on induction, which includes sepsis screening and management with reference to the sepsis screening and action tool.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 Incorporate sepsis screening into the Emergency Department Symphony system and train staff before implementation.
Verbatim wording from the response “• ED is currently undertaking work to incorporate the sepsis screening into the Symphony system used in ED, once this is completed further monitoring of compliance can be undertaken specifically for patients that present via ED. Staff training will be delivered to the MDT once this is completed prior to ‘go live’ date which is not confirmed.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 Complete weekly assurance audits of clinical records across acute areas, covering sepsis assessment and related discharge and communication safeguards.
Verbatim wording from the response “• In addition to the audit process, the Divisional Director of Nursing for Children & Neonates and the Matron for Children’s Services have developed an assurance tool, which is being completed weekly for a period of 12 weeks, auditing approximately 5 sets of clinical records every week from each acute area. Unlike the sepsis audit the assurance tool is not exclusive to patients with a clinical diagnosis of sepsis. The tool is designed to monitor the following which were areas of concern noted at the inquest:” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 Train paediatric consultants to review ICE results electronically and operate the electronic ICE system alongside a paper safety net.
Verbatim wording from the response “ICE training has taken place for all Paediatric consultants to enable them to review results electronically, and the electronic ICE system is now operational within the Paediatric department. The results are added to the folder of the requesting clinician and are available for clinicians to view electronically. The paper system remains in place as a safety net. There is a list of radiological findings that are listed in the red and amber list which leads to direct contact of the requesting clinician by the radiology team to highlight the results of an investigation. This is a failsafe system which has been in place in radiology for many years.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 Disseminate sepsis-learning and screening-tool messages through staff memoranda, the monthly Matron Newsletter and Clinical Governance meeting records.
Verbatim wording from the response “• A memo was issued by the Children’s Services Matron on 21 April 2021 to all members of the paediatric medical and nursing teams outlining actions following the SI investigation, including reference to the sepsis audit results and the need to improve compliance.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 approve the sepsis screening and action tool standard operating procedure through the specialty Clinical Governance meeting.
Verbatim wording from the response “• The sepsis screening and action tool Standard Operating Procedure (SOP) has been reviewed in line with review date of September 2021, this is currently shared for comments and will be approved at the specialty Clinical Governance meeting in October.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 Monitor paediatric sepsis-screening compliance through quarterly audits and report results to clinical governance and quality committees.
Verbatim wording from the response “Compliance with the Paediatric sepsis screening tool is being monitored proactively by the Paediatric Sepsis lead, Clinical Governance Lead for Paediatrics, and the Divisional Director of Nursing for Children & Neonates with the support of the clinical audit team. Results are collated at the end of each quarter and presented in a separate part of the clinical audit and effectiveness report. The current audit tool which reflects the report shared at the inquest, reviews the clinical records of all children admitted with a clinical coding of sepsis during the relevant time period. This includes children referred via the Emergency Department (ED), General Practitioner (GP) and Community Midwife (CMW).” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 Continue mandatory induction and multidisciplinary staff-development training on paediatric sepsis recognition, management and use of the screening tool.
Verbatim wording from the response “• Sepsis awareness training will remain on the mandatory induction programme for newly appointed staff; this specifically includes reference to the paediatric sepsis tool. Ongoing training is provided to staff within Paediatrics by way of MDT staff development days, which will continue to be delivered and include sessions provided by the Paediatric Consultant Lead for sepsis. This training which commenced in 2017, references the paediatric sepsis tool within clinical scenarios. Whilst this training was stepped down during the Covid-19 pandemic it re-commenced in April 2021 via MS Teams with monthly sessions being held since then.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 locum doctor’s access was available; the identified problem was use of a colleague’s credentials rather than a login failure.
Verbatim wording from the response “5. The risk of continuing Login issues when Locum doctors are working at the Trust” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 Established Trust and out-of-hours processes ensure locum doctors receive necessary IT access before commencing shifts.
Verbatim wording from the response “There is a Trust system which has been in place for several years to ensure locum doctors have access to the relevant and necessary IT. This system was in place prior to, and at the time of Jacob’s admission to hospital. Dr ████████, Executive Medical Director is assured that the availability of a log-in was not the issue in Jacob’s case, but the staff member, for reasons which are unclear, chose to use a colleague’s log-in details, rather than their own, which had been issued to them by the Trust in January 2014.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 Electronic ICE access, paper records and radiology red-and-amber alerts provide sufficient safeguards for reviewing paediatric investigation results.
Verbatim wording from the response “3. No alert/review system for ICE results yet in place for all the Paediatric team” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 Consultant handovers, case discussion and retrospective attendance-note review provide sufficient safeguards for children discharged without admission.
Verbatim wording from the response “All admitted paediatric patients are discussed with the consultant on service at each morning and evening handover as a routine practice across both sites, therefore, all admitted children are reviewed regularly by a Consultant during their admission. Patients referred that are deemed not to require admission following assessment by the ST4-8 Junior Doctor may be discussed with/reviewed by the Consultant of the week” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
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 Immediate sepsis treatment with clear documentation makes retrospective completion of the sepsis screening tool unnecessary.
Verbatim wording from the response “Comment for the patient with no sepsis screening and action tool completed for May-21:
Patient brought to ED resus ASHICE cardiac arrest alert, treated immediately as sepsis, therefore sepsis screening and action tool not completed, but very clear documentation.” Source location 2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
Open published response
26 Feb 2019 Kathleen McGeary · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 10 Failure to fully and properly assess vulnerable patients before discharge View source Failure to properly diagnose patients before discharge View source Failure to provide an adequate discharge summary View source Failure to fully and properly investigate patients before discharge View source Failure to provide prescribed antibiotics at discharge View source Failure of clear communication between clinicians and nursing staff View source Failure to assign clear responsibility for discharge decision making View source Failure to properly treat patients before discharge View source Failure to accurately record the identity of the discharging clinician View source Failure to address identified clinical and discharge failings through an effective plan View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kathleen McGeary · 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
Kathleen McGeary died on 6 March 2018 from a head injury sustained in a fall at Tuxford Manor Care Home after her discharge from hospital. Concerns included inadequate assessment and treatment before discharge, unclear responsibility for discharge decisions, inadequate discharge documentation and communication, and her leaving hospital without prescribed antibiotics.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully and properly assess vulnerable patients before discharge
Wider context from the report “1. There was little evidence that Mrs McGeary (who suffered from dementia and was vulnerable) was fully and properly assessed , investigated, diagnosed and treated before 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly diagnose patients before discharge
Wider context from the report “1. There was little evidence that Mrs McGeary (who suffered from dementia and was vulnerable) was fully and properly assessed, investigated, diagnosed and treated before 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an adequate discharge summary
Wider context from the report “3. The electronic discharge summary was inadequate and no paper discharge summary was produced . No explanation was given for this omission.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully and properly investigate patients before discharge
Wider context from the report “1. There was little evidence that Mrs McGeary (who suffered from dementia and was vulnerable) was fully and properly assessed, investigated, diagnosed and treated before 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prescribed antibiotics at discharge
Wider context from the report “4. Mrs McGeary left hospital by hospital arranged transport without the antibiotics she had been prescribed for a suspected UTI . No explanation was given for this failing.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clear communication between clinicians and nursing staff
Wider context from the report “2. No clinician took clear responsibility for discharging decision making. The recording of the identity of the discharging clinician was incorrect and communication between clinicians and nursing staff was unclear .
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign clear responsibility for discharge decision making
Wider context from the report “2. No clinician took clear responsibility for discharging decision making . The recording of the identity of the discharging clinician was incorrect and communication between clinicians and nursing staff was unclear.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly treat patients before discharge
Wider context from the report “1. There was little evidence that Mrs McGeary (who suffered from dementia and was vulnerable) was fully and properly assessed, investigated, diagnosed and treated before 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record the identity of the discharging clinician
Wider context from the report “2. No clinician took clear responsibility for discharging decision making. The recording of the identity of the discharging clinician was incorrect and communication between clinicians and nursing staff was unclear.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address identified clinical and discharge failings through an effective plan
Wider context from the report “5. At Inquest there appeared a culture of acceptance of the above failings and omissions without any corresponding will or effective plan to address them .
” 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 Replace the Symphony-Medisec link with a Medisec Viewer app that launches with Symphony and communicate its required use to all staff.
Verbatim wording from the response “I understand that during the inquest it was noted that a review of the past medical history from available hospital electronic notes (Medisec letter) was not undertaken which led to the ED team not being aware of her hyperparathyroidism. I would respond by saying that while, as heard in evidence, the Locum Doctor did not have access to Medisec, the Division have investigated this and found that the link between Symphony the system in ED and Medisec occasionally can be temperamental although all locums are provided with access to the Medisec system. On March 26 the current link button was removed from the Symphony system and replaced by a Medisec Viewer app that boots at the time Symphony is activated and is available for all to view and so far we have not experienced any problems with this following the update.” Source location 2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-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 Introduce a discharge checklist to improve discharge documentation and reduce recurrence of discharge omissions.
Verbatim wording from the response “I confirm that all patients are admitted under a named Consultant in ED though the pathway of care would of necessity involve other Consultants as in this case ████████. It will therefore be the case that care may be delivered by an individual other than the named individual on the admission record. We have audited 50 discharges from CDU over the last 3 months and found that in 86% of cases there was evidence of a discharge summary in the electronic notes, either in electronic format or in paper format which was subsequently scanned. We accept that this is clearly below the standard that is required and we have initiated a discharge checklist with immediate effect while the CDU standard operating procedure was being finalised. The discharge checklist is attached.” Source location 2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-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 Audit 50 CDU discharges over three months to assess whether discharge summaries were documented.
Verbatim wording from the response “I confirm that all patients are admitted under a named Consultant in ED though the pathway of care would of necessity involve other Consultants as in this case ████████. It will therefore be the case that care may be delivered by an individual other than the named individual on the admission record. We have audited 50 discharges from CDU over the last 3 months and found that in 86% of cases there was evidence of a discharge summary in the electronic notes, either in electronic format or in paper format which was subsequently scanned. We accept that this is clearly below the standard that is required and we have initiated a discharge checklist with immediate effect while the CDU standard operating procedure was being finalised. The discharge checklist is attached.” Source location 2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-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 Implement a CDU pathway document to support communication between the main hospital department and CDU on admission.
Verbatim wording from the response “the patient pathway. It also has CDU pathway document that aids the communication between the main hospital department and CDU on admission. This has now been implemented.” Source location 2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-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 Implement a CDU standard operating procedure defining responsibility across the patient pathway.
Verbatim wording from the response “We have developed a new CDU (Clinical Decision Unit) standard operating procedure, which I attach, where it makes clear where responsibility lies for various aspects of” Source location 2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-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 Continue developing an electronic CDU discharge summary and put it in place within three months.
Verbatim wording from the response “The Division will continue work on an electronic CDU discharge summary to further enhance the discharge process and aims to have this in place within the next 3 months.” Source location 2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-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 A CDU consultant made the discharge decision and identified the patient as medically fit for discharge, subject to specified conditions.
Verbatim wording from the response “The decision to discharge the patient was made by ████████ CDU Consultant on the ward rounds in the morning who clearly identified that the deceased was medically fit for discharge pending the outcome of the urine dipstick but required a RAPTS assessment. I am led to understand that should the RAPTS team at this stage have had any concerns they would have raised this with staff in ED and not continued with the discharge. I am advised that the team clearly stated that they had no concerns on this occasion. I am also advised by ████████ Patient Safety Lead who attended the Inquest that while the Care Home Manager said that the deceased “looked poorly when she arrived on an ambulance trolley and not in a wheelchair” she was not immediately worried and was happy to accept Mrs McGeary for observation for 24 hours.” Source location 2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-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 The patient received a thorough, appropriate emergency-department assessment for a condition usually managed in primary care.
Verbatim wording from the response ““I have reviewed the available online records for Mrs McGeary. I have not seen the paper notes. From the documentation available she appears to have presented with classical symptoms of lower urinary tract infection associated with delirium. I note a urine dipstick was negative but in the context of symptoms and the fever it will still be reasonable to treat as such as urinary symptoms are more strongly associated with UTI than is a dipstick. There were no features to suggest sepsis and examination from other sources of infection was carried out well. She has a documented normal neurological examination. She was not on any medication that was documented that would increase her risk of falling.” Source location 2019-0081-Response-by-Doncaster-and-Bassetlaw-Hospital-NHS-Trust
Open published response
Concerns raised 3 Failure to adhere to the Early Warning System for identifying and escalating deteriorating patients View source Failure to enter timed ward-round dictated notes in chronological order View source Failure to record clinician input following escalation in clinical notes 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
Roy Burgess · 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
Roy Burgess, aged 87, was admitted after a fall at home that caused a left femoral fracture and was transferred for surgery. The report identified missed opportunities to recognise and escalate his deteriorating condition, inadequate clinical record-keeping, and untimed ward-round notes entered non-chronologically. The inquest concluded that it was unlikely that intervention would have altered the outcome.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to the Early Warning System for identifying and escalating deteriorating patients
Wider context from the report “(1) The hospital Early Warning System used to identify and escalate a deteriorating patient was not adhered to. This allowed missed opportunities for Mr Burgess’s care to receive Senior Medical reviews which could have altered his management.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to enter timed ward-round dictated notes in chronological order
Wider context from the report “(3) Finally, untimed dictated notes of ward rounds , were then entered into the records in a non-chronological order , which was unhelpful and potentially misleading
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinician input following escalation in clinical notes
Wider context from the report “(2) Inadequate record keeping by clinician within the Clinical notes. There were numerous examples of care having been escalated by nursing staff to doctors but no record of their input following this escalation was entered in the notes , e.g. on 4th December 2017, Mr Burgess’s care was escalated between 11:40 hours and 16:30 hours on at least 5 occasions and no entries were placed in his clinical records . This could have had a detrimental effect on his care and if this practice continues it will potentially affect other patients.
” Open source report
Concerns raised 3 Failure to complete Enhanced Care Supervision daily assessments View source Failure to provide Enhanced Care Supervision in accordance with identified risk View source Failure to act on escalated concerns about insufficient supervision resources View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alfred William Meek · 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
Alfred William Meek, an 87-year-old man with dementia and cognitive impairment, suffered falls before and during his hospital admission and died on 13 September 2017. Concerns included missed or delayed Enhanced Care Supervision reviews, failure to provide supervision matching his assessed risk, and no evidence of further action after staff escalated concerns about insufficient resources.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Enhanced Care Supervision daily assessments
Wider context from the report “1) There was clear evidence of poor compliance with the Enhanced Care Supervision engagement policy and daily assessments . There was evidence before the Court of numerous days being missed and when the assessment was made the care was not provided in accordance with the policy or the level of risk identified leaving patient’s vulnerable to falls.
2) There was no evidence to suggest that any action was taken by the Trust following escalation by ward staff regarding concerns about the lack of resources to provide appropriate supervision in accordance with the level of risk identified.
The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to Enhanced Care Supervision and its implications, as ████████ is concerned that this situation could occur again.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Enhanced Care Supervision in accordance with identified risk
Wider context from the report “1) There was clear evidence of poor compliance with the Enhanced Care Supervision engagement policy and daily assessments. There was evidence before the Court of numerous days being missed and when the assessment was made the care was not provided in accordance with the policy or the level of risk identified leaving patient’s vulnerable to falls.
2) There was no evidence to suggest that any action was taken by the Trust following escalation by ward staff regarding concerns about the lack of resources to provide appropriate supervision in accordance with the level of risk identified.
The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to Enhanced Care Supervision and its implications, as ████████ is concerned that this situation could occur again.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on escalated concerns about insufficient supervision resources
Wider context from the report “1) There was clear evidence of poor compliance with the Enhanced Care Supervision engagement policy and daily assessments. There was evidence before the Court of numerous days being missed and when the assessment was made the care was not provided in accordance with the policy or the level of risk identified leaving patient’s vulnerable to falls.
2) There was no evidence to suggest that any action was taken by the Trust following escalation by ward staff regarding concerns about the lack of resources to provide appropriate supervision in accordance with the level of risk identified.
The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to Enhanced Care Supervision and its implications, as ████████ is concerned that this situation could occur again.
” 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 Undertake Trust-wide falls prevention audits to identify compliance and improvement needs.
Verbatim wording from the response “The Trust Falls Specialist Practitioner has also undertaken audits across the Trust and these can be found appended to this letter. This shows a broadly high level of compliance in respect of assessments being undertaken at the appropriate frequency and action for supervision being taken. There are some areas for improvement on the implementation of the relevant actions to address a patients specific falls risk factors/ and de-escalation interventions, which is supported through the training provided, subsequently described in this letter.” Source location 2018-0190-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospital-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 Conduct regular audits of daily reassessment and intervention reliability across wards.
Verbatim wording from the response “The first concern in your letter was regarding gaps in the reliability of daily reassessment and appropriate intervention. In response to this concern, I can confirm that our policies and documentation are designed to achieve an appropriate frequency of reassessment and appropriate interventions. The reliability of daily assessment and appropriate intervention can be seen through monitoring with regular audits. The total results for ward S12 are:” Source location 2018-0190-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospital-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 Implement falls ward accreditation, including staff training, supervision-assessment sign-off, monthly audits and monitoring for further support.
Verbatim wording from the response “The Trust action plan for Falls & Bone Health Management supports the falls ward accreditation to be implemented this year. This is similar to other accreditation initiatives already in place such as nutrition and infection control. The falls accreditation will provide proactive assurance of the work” Source location 2018-0190-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospital-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 Existing enhanced supervision systems, staffing assessments and resource-allocation procedures are considered sufficient to manage staffing after escalation.
Verbatim wording from the response “The second concern described in the letter was about the action taken following escalation. The investigation report found that the staff did not escalate any staffing needs, as they had not recognised the need for Mr Meek. This aspect relates to the reliability point above and there are systems in place through the Enhanced Supervision & Engagement Policy. The following steps set out the systematic approach that is in place to manage staffing resources optimisation:” Source location 2018-0190-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospital-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 Existing policies, documentation, monitoring and audits are considered sufficient to ensure reliable daily reassessment and appropriate intervention.
Verbatim wording from the response “The first concern in your letter was regarding gaps in the reliability of daily reassessment and appropriate intervention. In response to this concern, I can confirm that our policies and documentation are designed to achieve an appropriate frequency of reassessment and appropriate interventions. The reliability of daily assessment and appropriate intervention can be seen through monitoring with regular audits. The total results for ward S12 are:” Source location 2018-0190-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospital-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 Short-notice additional staffing responses remain limited by finite resources, temporary-staff fill rates, sickness and absence.
Verbatim wording from the response “The Trust is resourced with finite financial support, but when there is a clinical need for additional resources, additional resources will be requested from the nursing bank, provided by NHS Professionals. The fill rate for NHS Professionals is at about 80% of the demand for Heath Care Assistants, who are the staff group booked for supervision needs. Staff who already work for the Trust are asked to undertake additional duties, prioritised on part time staff, but would include overtime when other options have not been successful. If there is no-one available despite these attempts, then staff may be redeployed to spread the risk and optimise patient safety and safe staffing levels across the hospital. A limitation remains in achieving short notice responses, exacerbated when there is sickness and absence that creates additional demands for temporary staffing.” Source location 2018-0190-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospital-NHS-Trust
Open published response
21 Jul 2017 James David Allbones · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Failure of the Paediatric team to recognise and act on sepsis red flag signs View source Failure to ensure Consultant Paediatrician involvement in Emergency Department disposition decisions for critically ill children View source Failure to support frank discussion and staff speaking up about deteriorating children View source Insufficient Paediatric staffing at Bassetlaw Hospital View source Lack of a face-to-face medical handover protocol View source See 2 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
James David Allbones · 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 David Allbones, aged five, died from sepsis caused by Influenza B virus infection at Bassetlaw Hospital on 2 March 2016, after being admitted within 12 hours and having been unwell with cough and breathlessness. The report identified concerns that the seriousness of his condition and red-flag signs of sepsis were not recognised, sepsis fluid management was not given, Consultant management and review were limited, and he was not considered early for transfer to a hospital providing Paediatric Intensive Care. Further concerns included paediatric staffing, handover arrangements, and communication about deteriorating children.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Paediatric team to recognise and act on sepsis red flag signs
Wider context from the report “That the ‘red flag signs’ of sepsis will not be recognised and acted upon by the Paediatric team unless there is further training and awareness raising. I suggest The Paediatric Consultant team access external training and mentoring by senior colleagues ideally within their Critical Care network.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure Consultant Paediatrician involvement in Emergency Department disposition decisions for critically ill children
Wider context from the report “That a child as ill as James will again be moved from the Emergency Department to the ward or Assessment Unit at the Hospital, rather than being transferred out for ongoing care – there is no reassurance that a sick child will be seen by a Consultant Paediatrician in the Emergency Department to assist with this decision
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to support frank discussion and staff speaking up about deteriorating children
Wider context from the report “that the Consultant team have rejected a model of care that encourages frank discussion with nursing and other staff on the ward , aimed at helping all staff speak up when worried about a deterioration child (the RCPCH SAFE model)
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient Paediatric staffing at Bassetlaw Hospital
Wider context from the report “the level of Paediatric staffing at Bassetlaw Hospital . I understand there is often only one junior doctor available , and that the middle grade doctor is on duty for 24 hours .
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a face-to-face medical handover protocol
Wider context from the report “that there is still no protocol for face to face medical handover
” Open source report
5 Feb 2016 Douglas Kay · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Lack of a clear agreed policy or procedure for transferring patients with gastrointestinal bleeding View source Failure to ensure key senior staff are aware of how the gastrointestinal bleeding service operates out of hours View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Douglas Kay · 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
Douglas Kay, an elderly man aged 90, died approximately seven hours after becoming suddenly unwell with a catastrophic bleed from a duodenal ulcer on 22 November 2014. Outstanding concerns included confusion about transferring patients with gastrointestinal bleeding and a lack of awareness among key Bassetlaw Hospital staff about the arrangements for the Doncaster gastrointestinal bleeding service, particularly out of hours.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear agreed policy or procedure for transferring patients with gastrointestinal bleeding
Wider context from the report “There remain significant confusion, and uncertainty about how, and when, to transfer a patient with gastrointestinal bleeding , with no clear agreed policy or procedure available within the Trust
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure key senior staff are aware of how the gastrointestinal bleeding service operates out of hours
Wider context from the report “There are new arrangements for the provision of gastrointestinal bleeding service at Doncaster Hospital, but key Senior staff at Bassetlaw Hospital are not aware of how it operates, particularly out of hours .
” 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 Monitor implementation of the Upper GI Bleed Transfer Policy through the Emergency Care Group Clinical Governance Team and Datix incident system.
Verbatim wording from the response “I trust that this will provide the assurance you require that appropriate action has been taken following the death of Douglas Kay. The implementation will continue to be monitored by the Emergency Care Group Clinical Governance Team through the Datix incident system.” Source location DBH-Trust-Response
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 Submit the Upper GI Bleed Transfer Policy for ratification by the Patient Safety Review Group to support wider Trust dissemination.
Verbatim wording from the response “The policy will also be ratified at the next meeting of the Patient Safety Review Group and this will ensure wider dissemination throughout the Trust.” Source location DBH-Trust-Response
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 Make Bassetlaw staff aware of the specific Upper GI Bleed Transfer Policy through the Clinical Site Manager and Matron.
Verbatim wording from the response “All staff will be made aware of this specific transfer policy at Bassetlaw through the Clinical Site Manager and Matron at Bassetlaw.” Source location DBH-Trust-Response
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 an Upper GI Bleed Transfer Policy for Bassetlaw Hospital patients requiring transfer to Doncaster.
Verbatim wording from the response “which is particularly relevant in this case is the Upper GI Bleed Transfer Policy at Bassetlaw Hospital for those patients who require to be referred to Doncaster for further management of their upper GI bleeding. This policy has been developed after consultation between the anaesthetic and the medical teams.” Source location DBH-Trust-Response
Open published response
Concerns raised 12 Lack of clarity about paediatric sepsis signs and responses View source Lack of paediatric sepsis treatment protocol and guidance View source Inaccurate completion and scoring of the observation chart View source Poor communication between clinical staff View source Failure to record significant events and developments View source Lack of protocols for doctors to regularly review and assess observation charts View source Unavailability of a paediatric sepsis screening tool View source Lack of guidance for communicating with children with disabilities such as autism View source Ineffective or poorly understood dissemination system for key information and medical updates View source Delays in communicating microbiology results to staff responsible for assessment View source Unclear and interchangeable use of paediatric sepsis terminology View source Failure to obtain and properly consider relevant information from parents View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 11
Action
Remind medical and nursing staff that record keeping must meet Nursing and Midwifery Council and General Medical Council standards.
Stated completedThe respondent said that this action was complete when they made their response on 2 February 2016. View source
Action
Standardize PAWS documentation to record required physiological observations, colour, skin changes, individual scores, totals and observations directly on the chart.
Stated completedThe respondent said that this action was complete when they made their response on 2 February 2016. View source
Action
Require healthcare assistants and registered nurses to complete competency self-declarations for physiological observations, PAWS documentation, interpretation and escalation.
Stated completedThe respondent said that this action was complete when they made their response on 2 February 2016. View source
Action
Require staff receiving urgent blood results by telephone to record, sign, date, time and verbally communicate them to medical staff.
Stated completedThe respondent said that this action was complete when they made their response on 2 February 2016. View source
Action
Require clinical handovers to access microbiology results through ICE and document outstanding results for follow-up and action.
Stated completedThe respondent said that this action was complete when they made their response on 2 February 2016. View source
Action
Route key information and medical updates through the Patient Safety Review Group for dissemination to relevant clinical areas and implementation monitoring.
Stated completedThe respondent said that this action was complete when they made their response on 2 February 2016. View source
Action
Provide multidisciplinary training on paediatric sepsis and unexpected deterioration, including training for medical staff during each house induction.
Stated in progressThe respondent said that this action was in progress when they made their response on 2 February 2016. View source
Action
Review the Paediatric IPOC and require documentation of communication needs and disability-related communication limitations.
Stated completedThe respondent said that this action was complete when they made their response on 2 February 2016. View source
Action
Require all Trust consultants to audit clinical records as part of annual appraisal.
Stated completedThe respondent said that this action was complete when they made their response on 2 February 2016. View source
Action
Address identified staff training needs relating to accurate completion of paediatric warning scores.
Stated in progressThe respondent said that this action was in progress when they made their response on 2 February 2016. View source
Action
Implement and disseminate an agreed paediatric sepsis toolkit across clinical areas.
Stated completedThe respondent said that this action was complete when they made their response on 2 February 2016. View source See 8 more actions
×
AI-generated summary
Marc Jason Stephen Poole · 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
Marc Jason Stephen Poole, aged 6, was admitted to hospital on 16 May 2015 with suspected infection and died in Sheffield Children’s Hospital on 18 May 2015 from the effects of pneumococcal septicaemia. The report identified concerns about delayed antibiotic treatment, poor communication, inaccurate observation and warning-score recording, inadequate paediatric sepsis guidance, dissemination of medical information, and poor record keeping.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about paediatric sepsis signs and responses
Wider context from the report “(3) Sepsis in Paediatrics
It is clear that consideration should be given to developing a protocol and guidance for those treating children. A paediatric screening tool needs to be provided. There needs to be clear explanations of the terms septic, sepsis, septic shock, septicaemia, bacteraemia. These terms were used interchangeably. It needs to be made clear to staff the signs they should be looking out for and how these might be responded to.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of paediatric sepsis treatment protocol and guidance
Wider context from the report “(3) Sepsis in Paediatrics
It is clear that consideration should be given to developing a protocol and guidance for those treating children. A paediatric screening tool needs to be provided. There needs to be clear explanations of the terms septic, sepsis, septic shock, septicaemia, bacteraemia. These terms were used interchangeably. It needs to be made clear to staff the signs they should be looking out for and how these might be responded to.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate completion and scoring of the observation chart
Wider context from the report “(2) PAWS
The observation chart was poorly completed. There were occasions where incorrect scoring had been documented understating MJ’s condition at that time. This was a form and source of information said to have been heavily relied upon but no clear protocols for doctors to regularly review and assess. It would seem further training is required to ensure accurate completion of this form and accurate scoring.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor communication between clinical staff
Wider context from the report “(1) Poor communication on a number of levels
Insufficient discussion with the parents regarding history, insufficient weight attached to the information they did provide at the time of admission and subsequently. Absence of any protocols of guidance as to how best to communicate with children with disabilities such as autism as MJ had. Communications between staff were poor, HCAs to nurses, nurses to doctors and between junior doctors and senior doctors. Ineffective communication of microbiology results which had been phoned through to the ward but not immediately passed on to those who needed to undertake assessment.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record significant events and developments
Wider context from the report “(5) Poor record keeping
Even when a ward is busy, it is imperative that clear records are made of significant events or developments. There were a number of occasions where no record was made at all
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols for doctors to regularly review and assess observation charts
Wider context from the report “(2) PAWS
The observation chart was poorly completed. There were occasions where incorrect scoring had been documented understating MJ’s condition at that time. This was a form and source of information said to have been heavily relied upon but no clear protocols for doctors to regularly review and assess . It would seem further training is required to ensure accurate completion of this form and accurate scoring.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a paediatric sepsis screening tool
Wider context from the report “(3) Sepsis in Paediatrics
It is clear that consideration should be given to developing a protocol and guidance for those treating children. A paediatric screening tool needs to be provided. There needs to be clear explanations of the terms septic, sepsis, septic shock, septicaemia, bacteraemia. These terms were used interchangeably. It needs to be made clear to staff the signs they should be looking out for and how these might be responded to.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for communicating with children with disabilities such as autism
Wider context from the report “(1) Poor communication on a number of levels
Insufficient discussion with the parents regarding history, insufficient weight attached to the information they did provide at the time of admission and subsequently. Absence of any protocols of guidance as to how best to communicate with children with disabilities such as autism as MJ had. Communications between staff were poor, HCAs to nurses, nurses to doctors and between junior doctors and senior doctors. Ineffective communication of microbiology results which had been phoned through to the ward but not immediately passed on to those who needed to undertake assessment.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective or poorly understood dissemination system for key information and medical updates
Wider context from the report “(4) Dissemination of key information and medical updates
There needs to be a review of the systems currently in place for disseminating such information. I was not reassured from the evidence I heard that the current system is effective in that regard or fully understood by staff at the trust.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in communicating microbiology results to staff responsible for assessment
Wider context from the report “(1) Poor communication on a number of levels
Insufficient discussion with the parents regarding history, insufficient weight attached to the information they did provide at the time of admission and subsequently. Absence of any protocols of guidance as to how best to communicate with children with disabilities such as autism as MJ had. Communications between staff were poor, HCAs to nurses, nurses to doctors and between junior doctors and senior doctors. Ineffective communication of microbiology results which had been phoned through to the ward but not immediately passed on to those who needed to undertake assessment.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear and interchangeable use of paediatric sepsis terminology
Wider context from the report “(3) Sepsis in Paediatrics
It is clear that consideration should be given to developing a protocol and guidance for those treating children. A paediatric screening tool needs to be provided. There needs to be clear explanations of the terms septic, sepsis, septic shock, septicaemia, bacteraemia. These terms were used interchangeably. It needs to be made clear to staff the signs they should be looking out for and how these might be responded to.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and properly consider relevant information from parents
Wider context from the report “(1) Poor communication on a number of levels
Insufficient discussion with the parents regarding history, insufficient weight attached to the information they did provide at the time of admission and subsequently. Absence of any protocols of guidance as to how best to communicate with children with disabilities such as autism as MJ had. Communications between staff were poor, HCAs to nurses, nurses to doctors and between junior doctors and senior doctors. Ineffective communication of microbiology results which had been phoned through to the ward but not immediately passed on to those who needed to undertake assessment.
” 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 Remind medical and nursing staff that record keeping must meet Nursing and Midwifery Council and General Medical Council standards.
Verbatim wording from the response “It is acknowledged that record keeping was poor both from medical and nursing staff and I confirm the individuals who were involved in this case have reflected on this and the importance of recording care that is given to patients. Staff have been reminded that good record keeping is in line with what is expected by the Nursing and Midwifery Council and the General Medical Council Guidelines on record keeping. In respect of this all Consultants within the Trust are required to undertake an audit of clinical records as part of their yearly appraisal.” Source location Marc-Poole-Response
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 Standardize PAWS documentation to record required physiological observations, colour, skin changes, individual scores, totals and observations directly on the chart.
Verbatim wording from the response “1. In all instances the minimum recording on PAWS includes temperature measurement, pulse and heart rate measurement as well as frequency of respirations. This is documented together with the child’s colour at the time that such observations have been undertaken.” Source location Marc-Poole-Response
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 Require healthcare assistants and registered nurses to complete competency self-declarations for physiological observations, PAWS documentation, interpretation and escalation.
Verbatim wording from the response “4. Staff have been made aware of these changes in practice and have been required to complete a self-declaration form. This allows opportunity for individuals to inform the Line Manager if they require additional training relating to observations and PAWS. Each Healthcare Assistant is also asked to complete a self-declaration form indicating that they were competent to undertake and document physiological observations and to report to a Registered Nurse any observations/PAWS outside of normal parameters. Each Registered Nurse has been asked to complete a self-” Source location Marc-Poole-Response
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 Require staff receiving urgent blood results by telephone to record, sign, date, time and verbally communicate them to medical staff.
Verbatim wording from the response “With respect to ineffective communication of microbiology results, the team has considered the issue of outstanding test results and confirmed that during clinical handovers the results should be accessed through ICE. Any outstanding matters will form part of the documentation in the handover process in order to confirm that they are followed up and acted upon. In respect of receipt of urgent blood results from the laboratory via telephone, staff have been made aware that it is the responsibility of the individual taking the call to record the results on the IPOC and to verbally share the results with the medical staff as well as date, time and sign the entry and record the member of medical staff that the results have been shared with.” Source location Marc-Poole-Response
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 Require clinical handovers to access microbiology results through ICE and document outstanding results for follow-up and action.
Verbatim wording from the response “With respect to ineffective communication of microbiology results, the team has considered the issue of outstanding test results and confirmed that during clinical handovers the results should be accessed through ICE. Any outstanding matters will form part of the documentation in the handover process in order to confirm that they are followed up and acted upon. In respect of receipt of urgent blood results from the laboratory via telephone, staff have been made aware that it is the responsibility of the individual taking the call to record the results on the IPOC and to verbally share the results with the medical staff as well as date, time and sign the entry and record the member of medical staff that the results have been shared with.” Source location Marc-Poole-Response
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 Route key information and medical updates through the Patient Safety Review Group for dissemination to relevant clinical areas and implementation monitoring.
Verbatim wording from the response “The Trust has reviewed its systems for disseminating such information. The Sepsis tool kit was disseminated and implemented for adults but for some reason this was not achieved in paediatrics. The revised process involves such information being received by the Patient Safety Review Group (PSRG) and then disseminated through members of the group to the relevant areas where the information or update is relevant. The PSRG will monitor that guidance has been implemented. The Trust Sepsis Lead has undertaken to support the Paediatric team with monitoring of the implementation of the Sepsis tool.” Source location Marc-Poole-Response
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 multidisciplinary training on paediatric sepsis and unexpected deterioration, including training for medical staff during each house induction.
Verbatim wording from the response “areas. Multi-disciplinary staff development will continue to provide training on sepsis in children and unexpected deterioration in children. This training will include medical staff on induction for each house.” Source location Marc-Poole-Response
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 the Paediatric IPOC and require documentation of communication needs and disability-related communication limitations.
Verbatim wording from the response “With respect to the discussion with the parents regarding a child’s clinical history, in order to ensure better communication the team have reviewed the Paediatric IPOC. Staff have been made aware of the need to listen to parents and take their views into consideration when assessing the clinical picture in any child who is admitted. Should children suffer from disabilities, medical and nursing staff will record, under the respective part of the Paediatric IPOC, how such children are communicated with and whether their disability limits their ability to communicate with strangers and hence the need to have more detailed and in depth conversations with parents. This situation will continue to pertain throughout the child’s stay in hospital.” Source location Marc-Poole-Response
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 Require all Trust consultants to audit clinical records as part of annual appraisal.
Verbatim wording from the response “It is acknowledged that record keeping was poor both from medical and nursing staff and I confirm the individuals who were involved in this case have reflected on this and the importance of recording care that is given to patients. Staff have been reminded that good record keeping is in line with what is expected by the Nursing and Midwifery Council and the General Medical Council Guidelines on record keeping. In respect of this all Consultants within the Trust are required to undertake an audit of clinical records as part of their yearly appraisal.” Source location Marc-Poole-Response
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 Address identified staff training needs relating to accurate completion of paediatric warning scores.
Verbatim wording from the response “Staff have been made aware that at the inquest it was highlighted there were a number of poorly completed charts with incomplete scores during the episode of care. It was the case that temperature readings had been recorded without a corresponding record of the heart rate and respiratory rate being undertaken at the same time which will enable significance to be attached to the result and correctly identify scores. Any additional training needs for staff have been noted and are in process of being addressed.” Source location Marc-Poole-Response
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 Implement and disseminate an agreed paediatric sepsis toolkit across clinical areas.
Verbatim wording from the response “The inquest noted that there was lack of use of the sepsis tool kit and this is of significant concern both to your office as well as the Trust. Since the outcome of the inquest the Trust has worked rapidly to introduce such a tool based on the UK Sepsis Trust tool to which there has been both nursing and medical contribution. I attach the tool which has been agreed, implemented and disseminated in all the clinical” Source location Marc-Poole-Response
Open published response
14 Jul 2015 Emma Carpenter · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Lack of inpatient beds for mentally ill children and adolescents View source Lack of sustainable long-term commissioning for specialist eating disorder services for children and adolescents View source Lack of clear connections between mental health professionals and education pastoral care staff View source Failure of school nurses to attend multidisciplinary meetings reliably View source Lack of professional links between the specialist Eating Disorder Service and Bassetlaw Hospital 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
Emma Carpenter · 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
Emma Carpenter was treated as an outpatient by child and adolescent mental health services from February 2004 to November 2006 and died from multi-organ failure caused by severe anorexia nervosa. The report identified insufficient physical-health monitoring, lack of specialist paediatric or physician input, and delay in accessing effective inpatient treatment as concerns.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of inpatient beds for mentally ill children and adolescents
Wider context from the report “2. There remains still a national lack of provision of inpatient beds for mentally ill children and adolescents including those who suffer from eating disorders .
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of sustainable long-term commissioning for specialist eating disorder services for children and adolescents
Wider context from the report “1. Although the Trust has now set up a specialist Eating Disorder Service for children and adolescents, there is only short term funding in place for this service and a lack of commitment from Commissioners for its long term future .
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear connections between mental health professionals and education pastoral care staff
Wider context from the report “4. In the absence of school nurses, there is a lack of clear connections between the mental health professionals and those in the education system who have responsibility for the pastoral care of mentally ill children and adolescents .
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of school nurses to attend multidisciplinary meetings reliably
Wider context from the report “3. Although the view of mental health professionals was that it was important for school nurses to attend Multi Disciplinary Meetings to understand and assist with care planning, this does not happen on a regular, reliable basis due to lack of funding for school nurses.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of professional links between the specialist Eating Disorder Service and Bassetlaw Hospital
Wider context from the report “1. The Trust has now set up a specialist Eating Disorder Service for children and adolescents, and reports that although this service now has good professional links with named paediatricians at Kings Mill Hospital and Queen’s Medical Centre, there are no equivalent links with Bassetlaw Hospital .
” 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 engaging with Nottinghamshire Healthcare Trust’s services when paediatric support is needed.
Verbatim wording from the response ““Thank you for your letter of 20th July 2015 regarding the Regulation 28.
Following our conversation, we cannot anticipate any regular requirement from Doncaster and Bassetlaw Hospitals NHS Foundation Trust to provide paediatric support at Thorneywood Adolescent Unit. I am sure it would be adequate to agree any paediatric advice on a case by case basis should this ever be required. Please do get back to me if you need anything else.”” Source location 2015-0276-Response-by-Doncaster-and-Bassettlaw-Hospitals-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 Monitor the support arrangements through the paediatric clinical governance team.
Verbatim wording from the response “We have an identified Consultant and will actively engage with the services provided by Nottinghamshire Healthcare Trust as the need arises and will monitor these arrangements through the paediatric clinical governance team.” Source location 2015-0276-Response-by-Doncaster-and-Bassettlaw-Hospitals-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 Offer a formal service-level agreement to support Bassetlaw patients receiving treatment at Thorneywood Adolescent Unit.
Verbatim wording from the response “I wish to confirm that this Trust has communicated formally to Nottinghamshire Health Care Foundation Trust, to understand how we can support patients from the Bassetlaw area whilst receiving treatment in Thorneywood Adolescent Unit. We offered a formal service level agreement and a named consultant to be the link to the service.” Source location 2015-0276-Response-by-Doncaster-and-Bassettlaw-Hospitals-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 Identify a consultant to act as the link with Nottinghamshire Healthcare Trust’s eating disorder services.
Verbatim wording from the response “I wish to confirm that this Trust has communicated formally to Nottinghamshire Health Care Foundation Trust, to understand how we can support patients from the Bassetlaw area whilst receiving treatment in Thorneywood Adolescent Unit. We offered a formal service level agreement and a named consultant to be the link to the service.” Source location 2015-0276-Response-by-Doncaster-and-Bassettlaw-Hospitals-NHS-Trust
Open published response
13 Mar 2015 Philip Robinson · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 7 Failure to reliably record and communicate the Early Warning Score across healthcare staff View source Unavailability of senior medical review when a registrar is absent View source Unsatisfactory auditing of compliance with safe discharge arrangements and recording of the Early Warning Score on discharge View source Lack of clear guidelines for ECG decision-making in acute breathlessness View source Failure to reliably perform ECGs when clinically indicated View source Unclear interim arrangements for where the Early Warning Score is recorded View source Unavailability of the iHospital system for improving Early Warning Score recording View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Philip Robinson · 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
Philip Robinson developed vomiting, breathlessness, coughing up blood and pain before being assessed at Bassetlaw Hospital, discharged, and later readmitted in cardiac arrest. The inquest concluded that he died from an acute myocardial infarction with severe coronary artery disease, after the significance of his clinical condition was not appreciated by the treating team. Concerns included inadequate escalation and recording of Early Warning Scores, unclear guidance on ECG use, an extreme risk arising from the absence of senior medical review, and incomplete implementation of systems intended to improve monitoring.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably record and communicate the Early Warning Score across healthcare staff
Wider context from the report “The improved recording and communication of the EWS from Health Care assistant, to Nurse, to doctor as necessary, is not evident throughout 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of senior medical review when a registrar is absent
Wider context from the report “The risk of there being no one available to provide senior medical review when a registrar is absent remains an ‘extreme risk’
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsatisfactory auditing of compliance with safe discharge arrangements and recording of the Early Warning Score on discharge
Wider context from the report “The results from audits of compliance with safe discharge arrangements using a discharge stamp, including the recording of the Early Warning Score on discharge are unsatisfactory
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidelines for ECG decision-making in acute breathlessness
Wider context from the report “The medical staff involved in this Inquest do not agree with the SUI author, that an ECG was indicated during Mr Robinson’s admission. There are no clear guidelines to assist medical staff with this clinical decision making when a patient presents with acute breathlessness. An audit to monitor the threshold for performing an ECG has shown this is still not reliably performed when clinically indicated
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably perform ECGs when clinically indicated
Wider context from the report “The medical staff involved in this Inquest do not agree with the SUI author, that an ECG was indicated during Mr Robinson’s admission. There are no clear guidelines to assist medical staff with this clinical decision making when a patient presents with acute breathlessness. An audit to monitor the threshold for performing an ECG has shown this is still not reliably performed when clinically indicated
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear interim arrangements for where the Early Warning Score is recorded
Wider context from the report “The iHospital which undoubtedly will assist in improving EWS recording, is not yet in place. Implementation is planned for June 2015, and there is potential for delay. Interim plans for a ‘At a glance Board’ are not clear, with confusion as to where the EWS will be recorded.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of the iHospital system for improving Early Warning Score recording
Wider context from the report “The iHospital which undoubtedly will assist in improving EWS recording, is not yet in place. Implementation is planned for June 2015, and there is potential for delay. Interim plans for a ‘At a glance Board’ are not clear, with confusion as to where the EWS will be recorded.
” 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 Implement the i-Hospital system to identify high EWS patients, due observations and discharge EWS assessment opportunities.
Verbatim wording from the response “The i-Hospital white board system is due for implementation later this year. This will highlight which patients have a high EWS and the next due time of observations. On discharging a patient from the system, the system will provide the nurse with an additional opportunity to assess EWS on discharge.” Source location 2015-0225-Response-by-Doncaster-Bassetlaw-Hospitals-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 Consider alternative ways to deploy senior Trust staff to provide out-of-hours support.
Verbatim wording from the response “• The risk of there being no one available to provide senior medical review when a registrar is absent remains an ‘extreme risk’
This is now no longer seen as an acceptable option to leave a SHO without registrar cover out of hours. In 2015 to date there has been three occasions where no cover could be obtained. On these occasions the consultant on-call was informed and provided extra support to the SHO. The issue around senior medical staffing remains a concern within the Trust. We currently have an ongoing recruitment programme and are considering alternative ways to utilise senior staff within the trust to support this. The hospital 24/7 program is aimed at providing senior nurse practitioner cover to support the hospital out of hours. Similar hospital sites have implemented this system with good outcomes with regards patient safety.” Source location 2015-0225-Response-by-Doncaster-Bassetlaw-Hospitals-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 Embed ward safety briefings and provide education to improve multidisciplinary communication of EWS.
Verbatim wording from the response “• The improved recording and communication of the EWS from Health Care assistant, to Nurse, to doctor as necessary, is not evident throughout the Hospital
The safety brief at the end of the ward round involves the whole of the ward team including HCA’s to improve communication of EWS between all the Multi-disciplinary team. The observations project has been completed and education undertaken with respect to the importance of clear communication between all members of the team. A safety brief is embedded in practice between shift change overs to improve whole team awareness of issues on the whole unit.
Audits on ATC of documentation of EWS by HCA in the notes have consistently improved, reducing the chance of verbal communication failure. Recent audits show 100% compliance with the escalation policy on ATC.” Source location 2015-0225-Response-by-Doncaster-Bassetlaw-Hospitals-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 Continue recruiting senior medical staff to reduce out-of-hours registrar-cover gaps.
Verbatim wording from the response “• The risk of there being no one available to provide senior medical review when a registrar is absent remains an ‘extreme risk’
This is now no longer seen as an acceptable option to leave a SHO without registrar cover out of hours. In 2015 to date there has been three occasions where no cover could be obtained. On these occasions the consultant on-call was informed and provided extra support to the SHO. The issue around senior medical staffing remains a concern within the Trust. We currently have an ongoing recruitment programme and are considering alternative ways to utilise senior staff within the trust to support this. The hospital 24/7 program is aimed at providing senior nurse practitioner cover to support the hospital out of hours. Similar hospital sites have implemented this system with good outcomes with regards patient safety.” Source location 2015-0225-Response-by-Doncaster-Bassetlaw-Hospitals-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 Complete an observations project improving documentation and recognition of EWS at discharge.
Verbatim wording from the response “• The results from audits of compliance with safe discharge arrangements using a discharge stamp, including the recording of the EWS on discharge are unsatisfactory.
The discharge stamp was trialled and found to be unsuccessful within ATC with its high turnover of patients.
Since this incident ATC has undergone an “observations project” which included the documentation and recognition of EWS on discharge.” Source location 2015-0225-Response-by-Doncaster-Bassetlaw-Hospitals-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 Embed a status-at-a-glance board showing EWS scores and due observation times on ATC.
Verbatim wording from the response “• The i-Hospital is not yet in place. Implementation is planned for June 2015, and there is potential for delay. Interim plans for a ‘At a glance Board’ are not clear, with confusion as to where the EWS will be recorded.
The “status at a glance” board is now embedded in practice on ATC. The board shows the EWS Score and the next time observations are due to be performed. The i-Hospital program is progressing well and plans remain optimistic that it will be in place by late summer 2015.” Source location 2015-0225-Response-by-Doncaster-Bassetlaw-Hospitals-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 Medical staff dispute that an ECG was indicated for acute breathlessness during the admission.
Verbatim wording from the response “• The medical staff involved in this Inquest do not agree with the SUI author, that an ECG was indicated during Mr Robinson’s admission. There are no clear guidelines to assist medical staff with this clinical decision making when a patient presents with acute breathlessness. An audit to monitor the threshold for performing an ECG has shown this is still not reliably performed when clinically indicated
There are no clear national guidelines to assist medical staff when ordering ECGs in patients who present with breathlessness. Acute medicine at Bassetlaw relies on early senior review by consultants. However variation in clinical judgement will occur. This incident has been communicated widely within the emergency care group by way of awareness.” Source location 2015-0225-Response-by-Doncaster-Bassetlaw-Hospitals-NHS-Trust
Open published response
Concerns raised 3 Failure to document haematoma location and size View source Failure to document Glasgow Coma Score assessments and results View source Failure to undertake and document complete clinical observations 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
Zakariyya Thomas Clark · 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
Zakariyya Clark was injured after being dropped, sustaining skull fractures and minor brain bleeds, but was discharged from hospital without a CT scan. He was later found unresponsive after sleeping and was declared dead; the inquest concluded that the death was due to Sudden Infant Death Syndrome and natural causes. The principal concern was that full assessments and observations were not carried out or documented when babies and children attended the emergency department, potentially putting future patients at risk.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document haematoma location and size
Wider context from the report “At the time of Zakariyya's attendance at the Doncaster Royal Infirmary on the 11th July 2013, there were significant deficiencies in both the matters recorded in the notes and the extent of the examination and assessment undertaken. These can be summarised as follows:
1. Failure to document an assessment of Glasgow Coma Score and the result.
2. Failure to document the location of the haematoma as well as its size.
3. Failure to follow Trust procedures in undertaking and documenting complete observations (blood pressure, heart rate, respiratory rate, temperature, saturations, capillary refill).
Ultimately, I concluded that these matters did not affect the outcome in Zakariyya's case but did feel that should these practices continue, future patients may well be at risk. Counsel for the family suggested to the Consultant in Emergency Medicine that the computerised systems described during evidence could be enhanced to ensure that clinicians could not move onto the next step until these vital observations had been undertaken and documented. The Consultant responded very positively to this suggestion. In essence therefore my concern is that failure to carry out full and complete assessments and observations in babies and children attending the Accident and Emergency department and then to document the same will put future patients at risk until these matters are properly addressed.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document Glasgow Coma Score assessments and results
Wider context from the report “At the time of Zakariyya's attendance at the Doncaster Royal Infirmary on the 11th July 2013, there were significant deficiencies in both the matters recorded in the notes and the extent of the examination and assessment undertaken. These can be summarised as follows:
1. Failure to document an assessment of Glasgow Coma Score and the result.
2. Failure to document the location of the haematoma as well as its size.
3. Failure to follow Trust procedures in undertaking and documenting complete observations (blood pressure, heart rate, respiratory rate, temperature, saturations, capillary refill).
Ultimately, I concluded that these matters did not affect the outcome in Zakariyya's case but did feel that should these practices continue, future patients may well be at risk. Counsel for the family suggested to the Consultant in Emergency Medicine that the computerised systems described during evidence could be enhanced to ensure that clinicians could not move onto the next step until these vital observations had been undertaken and documented. The Consultant responded very positively to this suggestion. In essence therefore my concern is that failure to carry out full and complete assessments and observations in babies and children attending the Accident and Emergency department and then to document the same will put future patients at risk until these matters are properly addressed.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake and document complete clinical observations
Wider context from the report “At the time of Zakariyya's attendance at the Doncaster Royal Infirmary on the 11th July 2013, there were significant deficiencies in both the matters recorded in the notes and the extent of the examination and assessment undertaken. These can be summarised as follows:
1. Failure to document an assessment of Glasgow Coma Score and the result.
2. Failure to document the location of the haematoma as well as its size.
3. Failure to follow Trust procedures in undertaking and documenting complete observations (blood pressure, heart rate, respiratory rate, temperature, saturations, capillary refill).
Ultimately, I concluded that these matters did not affect the outcome in Zakariyya's case but did feel that should these practices continue, future patients may well be at risk. Counsel for the family suggested to the Consultant in Emergency Medicine that the computerised systems described during evidence could be enhanced to ensure that clinicians could not move onto the next step until these vital observations had been undertaken and documented. The Consultant responded very positively to this suggestion. In essence therefore my concern is that failure to carry out full and complete assessments and observations in babies and children attending the Accident and Emergency department and then to document the same will put future patients at risk until these matters are properly addressed.
” Open source report
Concerns raised 3 Failure to notify Social Services of discharge contrary to their recommendations View source Lack of clarity in communicating post-discharge supervision expectations to informal carers View source Failure to maintain complete and accurate records of discharge decisions and timing 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
ROSEMARY BRONWYN FERGUSON · 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
ROSEMARY BRONWYN FERGUSON, who had a long-standing history of epilepsy, was admitted after a head injury from a fall and was assessed as unfit for discharge because of risks associated with further falls. Despite recommendations that she remain in hospital, she was discharged to the care of a friend and was found deceased alone at home on 11 March 2013; the medical cause of death was recorded as sudden unexpected death in epilepsy. The principal concerns were that Social Services were not notified of the discharge, the friend’s expected role was unclear, and hospital records did not adequately document key communications and the date of discharge.
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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify Social Services of discharge contrary to their recommendations
Wider context from the report “(1) The social workers left work on Friday 8th March, 2013 believing that, following their recommendations, Ms Ferguson would remain in hospital over the weekend and accordingly they did not put into place any support measures for her. The clinician’s decision to discharge her before support measures could be put in place was not communicated to Social Services. If it had been, this would have given an opportunity for them to take urgent supportive action. As it transpired, Ms Ferguson died from Natural causes rather than, for example, Injuries sustained in a further fall, or a deterioration of her earlier head injury, but I apprehend danger in the future if discharge occurs contrary to Social Service recommendations without the discharge being notified to 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in communicating post-discharge supervision expectations to informal carers
Wider context from the report “(2) The clinician discharged Ms Ferguson based on clinical issues and NICE guidelines. She was discharged to the care of her friend ████████ The only conversation between the clinicians and ████████ was a telephone call in which it was arranged for Ms Ferguson to be driven straight to his home on leaving hospital. This duly took place, but ████████ did not understand that the clinician expected him to remain in her company for at least the next 24 hours in order to watch for any significant changes in her condition and accordingly, he did not remain with her constantly. There was clearly a difference of perception about his role, possibly as a result of lack of clarity in the conversation between himself and the clinician. I am concerned that a repetition of this in other cases may lead to danger.
” 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 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain complete and accurate records of discharge decisions and timing
Wider context from the report “(3) The Hospital Notes were scanty and there appear to be material omissions to record important decisions such as a detailed note of the telephone call between ████████ and the clinician, properly timed and recording clearly what was intended . Further, it was difficult to trace from the Notes, the actual day of discharge , the clinician believing it to be the 8th March and ████████ believing it was the 9th March. Some computer records were presented to the Court suggestive of a discharge on the 8th March, but this information appears to be missing from the actual hand-written Notes . I am concerned that such problems with communication can lead to misunderstandings to the detriment of all concerns.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations