Recipient

Doncaster Royal Infirmary

First report 4 Jul 2016•Latest report 20 Jan 2026

Recipient record

Reports, concerns and published responses

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

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

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

20 Jan2026
South Yorkshire (Eastern)
Concerns raised5
1. Failure to follow up Nerve Centre system escalation triggers
2. Lack of clear direction from the attending doctor following a fall
3. Lack of a clear plan for the frequency and duration of neurological observations following a fall
1. Failure to complete inpatient post-fall reviews
2. Failure to properly complete Nerve Centre system escalation records
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

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 Royal Infirmary; 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 Royal Infirmary; 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 Royal Infirmary; 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 Royal Infirmary; 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 Royal Infirmary; 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
22 Aug2025
South Yorkshire (Eastern)
Concerns raised3
1. Failure of systems and documentation to identify whether requested investigations had been performed
2. Failure to control and record cancellation of tests and actions by temporary or unauthorised users
3. Failure to maintain accurate medical records and communicate information needed for urgent tests
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

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 Royal Infirmary; 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 Royal Infirmary; 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 Royal Infirmary; 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
2 Apr2024
South Yorkshire (Eastern)
Concerns raised3
1. Poor and inconsistent clinical record keeping on the ward
2. Poor and inaccurate communication with families following incidents
3. Lack of a system for agency staff to access and communicate reminders and new policies and procedures
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

Robert Fuller · 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

Robert Fuller was admitted to Doncaster Royal Infirmary with increased confusion and later suffered an assault by another patient, causing him to fall and sustain a traumatic brain bleed. He subsequently deteriorated and died on 22 July 2022; the inquest concluded that he died from natural causes, with pathology confirming that the assault-related injuries did not cause or contribute to his death. Concerns included poor record keeping, inadequate communication with the family after the incident, and the lack of a system for agency staff to access and communicate reminders, policies and procedures.

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 Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation
Poor and inconsistent clinical record keeping on the ward
Wider context from the report
“1. There was evidence of poor record keeping on the ward. This included behaviour charts, enhanced patient supervision records and daily evaluation charts not being consistently recorded. There was either no or poor documentation of other professionals entering the ward and evaluating patients, and the outcome of such assessments not being recorded. Some of the documentation was also described as not fit for purpose within the frailty unit due to the needs of the patients. This insufficient record keeping prevented any patterns of challenging behaviour to be assessed and managed accordingly putting other patients, staff and visitors at risk of harm. ”
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 Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation
Poor and inaccurate communication with families following incidents
Wider context from the report
“2. This poor record keeping also lead to poor/inaccurate communication following the incident with the family. ”
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 Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation
Lack of a system for agency staff to access and communicate reminders and new policies and procedures
Wider context from the report
“3. There is no system in place for agency staff, who frequently work on the Frailty Unit to access and communicate , reminders or new policies and procedures. ”
Open source report
22 Feb2018
South Yorkshire (Eastern)
Concerns raised2
1. Lack of checking of verbally prescribed drugs before administration
2. Poor quality and incomplete clinical record keeping
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 Robert Quinton · 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 Robert Quinton collapsed after a period of vomiting and abdominal pain, with the inquest recording splenic rupture and combined morphine and methadone toxicity, alongside rivaroxaban therapy, as the cause of death. He did not respond to resuscitation and supportive measures. Concerns included poor-quality nursing and observation records, and noradrenaline intended as an infusion being administered as an intravenous bolus during resuscitation.

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 Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation
Lack of checking of verbally prescribed drugs before administration
Wider context from the report
“(2) Furthermore, during the course of the resuscitation a decision was made for Mr Quinton to be given 4 mgs of Noradrenaline. This was to be given as an infusion. Unfortunately, this was actually given as a 4 mg iv bolus. Although the records suggest this did not have a detrimental effect on Mr Quinton (his blood pressure had been exceptionally low) this clearly could be highly significant for other patients. It also raises the question of other patients being given either the wrong drug or the wrong amount of drug or the wrong method of administration when the procedure for drugs to be prescribed in this scenario is on a verbal basis only. It would seem sensible to have some checking procedure by the person administering the drugs checking with the person who had prescribed it to make sure their understanding is correct. From the evidence I heard it seems there are no such procedures in 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 Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation
Poor quality and incomplete clinical record keeping
Wider context from the report
“(1) During the course of the evidence it became clear that the poor quality nursing notes and the lack of information of the observation chart made it difficult for the reviewing Consultants to get a clear picture of events that had been occurring. Clearly poor record keeping has significant implications for patients. ”
Open source report
4 Dec2017
South Yorkshire (Eastern)
Concerns raised4
1. Delays in providing thromboprophylaxis exceeding 24 hours
2. Failure to fully complete mandatory VTE risk assessments
3. Failure of consultant VTE assessment to identify incomplete VTE risk assessments
1. Failure to document consultant VTE assessments
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

Gordon Frank Thornhill · 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

Gordon Frank Thornhill, a 61-year-old man, developed abdominal pain, attended A&E twice, and collapsed and died at home on 13 April 2017. The report identified incomplete VTE risk assessment, failure to identify that omission, undocumented consultant assessment, and a delay of more than 24 hours in providing thromboprophylaxis; the inquest conclusion was natural causes, with death from pulmonary embolism following DVT development.

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 Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation
Delays in providing thromboprophylaxis exceeding 24 hours
Wider context from the report
“(4) A delay in excess of 24 hours in providing thromboprophylaxis. ”
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 Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation
Failure to fully complete mandatory VTE risk assessments
Wider context from the report
“(1) Junior doctor's failure to fully complete the mandatory VTE risk 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 Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation
Failure of consultant VTE assessment to identify incomplete VTE risk assessments
Wider context from the report
“(2) The Consultant’s VTE assessment done the day following admission failed to identify incomplete/failure to complete VTE risk 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 Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation
Failure to document consultant VTE assessments
Wider context from the report
“(3) The Consultant carried out his own assessment as a “mental exercise” and did not document his assessment. ”
Open source report
4 Jul2016
South Yorkshire (Eastern)
Concerns raised1
1. Use of fluticasone in patients without a raised eosinophil count carrying pneumonia risk without benefit
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Thomas William Pearson · Prevention of Future Deaths report

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

Report summary

Thomas William Pearson, a retired coal miner with chronic obstructive pulmonary disease and rheumatoid arthritis, died at Doncaster Royal Infirmary on 11 February 2016 after suffering recurrent pneumonia and debilitating breathlessness. The report raised concern that long-term inhaled fluticasone use increased his risk of pneumonia and may have provided no benefit for patients without a raised eosinophil count, and noted that review of inhaled steroid use would be helpful.

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 Royal Infirmary; that does not assign responsibility.
PFD Monitor interpretation
Use of fluticasone in patients without a raised eosinophil count carrying pneumonia risk without benefit
Wider context from the report
“(4) Dr T Rogers (Consultant Respiratory Physician), who gave evidence at the inquest, confirmed that fluticasone causes a reduction in the body's defence mechanisms and, as a result, carries with it an increased risk (estimated at 1.7 fold) increase in the risk of the patient developing pneumonia. (5) For a proportion of patients, the increased risk of developing pneumonia may be justified by the benefits that the use of fluticasone brings. However, Dr Rogers also stated that, for the majority of patients, namely those without a raised eosinophil count (a group which included Mr Pearson), fluticasone, whilst still carrying an increased risk of the development of pneumonia, would bring no benefits. (6) In response to an enquiry put to him, Dr Rogers agreed that it would be helpful for the use of inhaled steroids (in particular fluticasone) to be reviewed. ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised5

Failure to follow up Nerve Centre system escalation triggers

Lack of clear direction from the attending doctor following a fall

Lack of a clear plan for the frequency and duration of neurological observations following a fall

Failure to complete inpatient post-fall reviews

Failure to properly complete Nerve Centre system escalation records

Concerns raised3

Failure of systems and documentation to identify whether requested investigations had been performed

Failure to control and record cancellation of tests and actions by temporary or unauthorised users

Failure to maintain accurate medical records and communicate information needed for urgent tests

Concerns raised3

Poor and inconsistent clinical record keeping on the ward

Poor and inaccurate communication with families following incidents

Lack of a system for agency staff to access and communicate reminders and new policies and procedures

Concerns raised2

Lack of checking of verbally prescribed drugs before administration

Poor quality and incomplete clinical record keeping

Concerns raised4

Delays in providing thromboprophylaxis exceeding 24 hours

Failure to fully complete mandatory VTE risk assessments

Failure of consultant VTE assessment to identify incomplete VTE risk assessments

Failure to document consultant VTE assessments

Concerns raised1

Use of fluticasone in patients without a raised eosinophil count carrying pneumonia risk without benefit