28 May 2024 Christine Rita Booker · Prevention of Future Deaths report Dorset
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Concerns raised 2 Unavailability of out-of-hours interventional radiology at Dorset County Hospital View source Delays in urgent interventional radiology treatment caused by required inter-hospital transfer View source
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. 1
Action
Audit interventional radiology transfer times and compliance with decision-to-transfer standards with University Hospitals Dorset.
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AI-generated summary
Christine Rita Booker · 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
Christine Rita Booker underwent elective right total hip replacement surgery on 23 February 2023 and became critically unwell after extensive bleeding, subsequently dying at Royal Bournemouth Hospital on 24 February 2023. The report raises concern that the lack of out-of-hours interventional radiology at Dorset County Hospital required urgent patients to be transferred, potentially causing significant delays to life-saving treatment and increasing the risk of death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset County Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of out-of-hours interventional radiology at Dorset County Hospital
Wider context from the report “1. During the inquest evidence was heard that:
i. There is no out of hours interventional radiology at Dorset County Hospital and that patients requiring this potentially urgent and life-saving intervention that live in the West of the County require transfer to the Royal Bournemouth Hospital for treatment.
2. I have concerns with regard to the following:
i. Because of the lack of out of hours interventional radiology at Dorset County Hospital , patients in the West of the County requiring such an intervention must be transferred to the Royal Bournemouth Hospital. This exposes these patients to a potentially considerable and significant delay in the provision of urgent and life-saving treatment, which, in turn, exposes them to an increased risk of death.
” 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 Dorset County Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in urgent interventional radiology treatment caused by required inter-hospital transfer
Wider context from the report “1. During the inquest evidence was heard that:
i. There is no out of hours interventional radiology at Dorset County Hospital and that patients requiring this potentially urgent and life-saving intervention that live in the West of the County require transfer to the Royal Bournemouth Hospital for treatment .
2. I have concerns with regard to the following:
i. Because of the lack of out of hours interventional radiology at Dorset County Hospital, patients in the West of the County requiring such an intervention must be transferred to the Royal Bournemouth Hospital . This exposes these patients to a potentially considerable and significant delay in the provision of urgent and life-saving treatment , which, in turn, exposes them to an increased risk of death.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit interventional radiology transfer times and compliance with decision-to-transfer standards with University Hospitals Dorset.
Verbatim wording from the response “The Trust is committed to continuous learning from any incident to strengthen the services for which it is responsible. Therefore we are carrying out an investigation of the management of this case as it pertains to Dorset County Hospital and will request sight of the report from the Winterborne Circle Hospital. In conjunction with UHD we are auditing the transfer times for interventional radiology between the two sites and our compliance with ‘decision to transfer’ standards. We will continue to monitor the service to ensure our clinical decision making and access to services are in place for all current and future patients.” Source location Response from Dorset County Hospital
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England, as commissioner, is responsible for addressing the provision of 24/7 emergency specialist interventional radiology.
Verbatim wording from the response “We have reviewed the findings of the inquest, and the recommendations as stated in the Preventing Future Deaths report and can confirm that the Trust does not provide a 24/7 emergency service for specialist interventional radiology for embolization. This is a specialised service commissioned by NHS England, provided by University Hospitals Dorset from their site at the Royal Bournemouth Hospital for both Dorset County Hospital and Salisbury Hospital. 24/7 specialised interventional radiology services are not available in every local hospital because they are delivered by specialist teams who have the necessary skills, experience and volume of work to maintain safe standards of care across wider geographical areas.” Source location Response from Dorset County Hospital
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The commissioned blue-light transfer pathway and monitoring mechanisms provide assurance of timely and safe access to emergency interventional radiology.
Verbatim wording from the response “The commissioned pathway of care, for those requiring emergency specialist interventional radiology who attend Dorset County Hospital, is for ‘blue light transfer’ to the Royal Bournemouth Hospital, or other tertiary centre, via the ambulance service or in time critical situations by helicopter.” Source location Response from Dorset County Hospital
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5 Jun 2018 Rosemary Scott · Prevention of Future Deaths report Dorset
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Concerns raised 3 Lack of a reminder system for required venous blood gas measurements View source Insufficient availability of machines to provide PEEP to patients who require it View source Failure to measure venous blood gases when required by the Sepsis Six Pathway View source
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. 4
Action
Establish a divisional plan to address PEEP machine availability.
View source
Action
Decontaminate the unavailable PEEP unit and return it to service.
View source
Action
Rent and deliver three loan PEEP units to increase available capacity.
View source
Action
Submit a requisition for two replacement PEEP units.
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AI-generated summary
Rosemary Scott · 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 Scott suffered a fall, developed a chest flail segment and pneumonia, and died in hospital on 30 December 2017 after deterioration requiring respiratory support. Concerns included the absence of venous blood gas measurements and a reminder system, and insufficient availability of machines to provide the required positive end-expiratory pressure.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset County Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a reminder system for required venous blood gas measurements
Wider context from the report “2. I have concerns with regard to the following:
i. Due to the lack of a reminder system in relation to measuring venous blood gases it was not known whether the respiratory support being provided to Mrs Scott should have been escalated to a BiPAP or CPAP. I request that a review is undertaken to assess whether there should be a system installed to ensure the staff caring for patients where venous blood gases should have been measured are “reminded” of the need to do so.
ii. The insufficient number of machines to provide PEEP to patients who require it.
” 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 Dorset County Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of machines to provide PEEP to patients who require it
Wider context from the report “2. I have concerns with regard to the following:
i. Due to the lack of a reminder system in relation to measuring venous blood gases it was not known whether the respiratory support being provided to Mrs Scott should have been escalated to a BiPAP or CPAP. I request that a review is undertaken to assess whether there should be a system installed to ensure the staff caring for patients where venous blood gases should have been measured are “reminded” of the need to do so.
ii. The insufficient number of machines to provide PEEP to patients who require it.
” 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 Dorset County Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to measure venous blood gases when required by the Sepsis Six Pathway
Wider context from the report “1. During the inquest evidence was heard that:
i. Venous blood gases were not measured on the second admission (25th December to 30th December), in accordance with the Sepsis Six Pathway. There appeared to be no reminder system in place to address this omission. I heard evidence that measuring the carbon dioxide levels would have assisted in determining whether the high flow machine was providing the level of respiratory support Mrs Scott required.
ii. There were initially no means to provide PEEP to a patient that was deemed to need it, due to all machines being in use, or there simply being no machine in respiratory medicine.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a divisional plan to address PEEP machine availability.
Verbatim wording from the response “The medical records dated 28 December 2017, indicate that on only three PEEP machines were available across the hospital and that there was difficulty in locating one for use by Mrs Scott. I have investigated this matter and I would advise you that the Trust actually has 6 machines. However, at the time of Mrs Scott’s admission, two machines had been taken out of service as they were physically damaged and were being repaired. This left the Trust with four units. This concern was discussed at a Divisional level and a plan was put in place.” Source location 2018-0172-Response-by-Dorset-County-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Decontaminate the unavailable PEEP unit and return it to service.
Verbatim wording from the response “On 27 December 2017, a further unit was taken out of service for infection control reasons, which left three units across the hospital. The unit was decontaminated and returned to service on 29 December 2017.” Source location 2018-0172-Response-by-Dorset-County-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Rent and deliver three loan PEEP units to increase available capacity.
Verbatim wording from the response “On 28 December 2017, three loan units were rented for a period of two months and were delivered to site on 29 December 2017. This meant that between 08:00hrs to 15:00hrs three units were available, but by 16:00hrs, six units were available.” Source location 2018-0172-Response-by-Dorset-County-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Submit a requisition for two replacement PEEP units.
Verbatim wording from the response “I would also advise you that over this period the Trust had no incidents reported in relation to the unavailability of the units, and patient care had not been compromised. This incident was the first reported, therefore there is no evidence of a systemic issue/failure or a trend with respect to safety related to the unavailability of equipment. The rental units were in place within hours of the request being submitted, and a requisition for two replacement units was placed on 25 January 2018.” Source location 2018-0172-Response-by-Dorset-County-Hospital-NHS-Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing handover and clinical monitoring systems are considered sufficient; a blanket venous blood gas reminder cannot accommodate individual clinical judgment.
Verbatim wording from the response “I have been informed that it would be clearly indicated in the medical records that staff within the emergency department had been unable to access veins to gain venous gases. The decision, as to whether these would be clinically necessary would lie with the clinicians. As a patient’s condition changes, the clinical review of tests required can change. This is part of the individual clinician’s judgement and assessment of the patient.” Source location 2018-0172-Response-by-Dorset-County-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A suitable alternative PEEP unit was in place under the consultant’s care plan, so patient care was not compromised during the temporary shortage.
Verbatim wording from the response “On reviewing the records and the events, Mrs Scott was without the unit for only a few hours and this was neither detrimental to her care, nor a factor in her death. A suitable alternative was in place and in use, as per the consultant’s care plan.” Source location 2018-0172-Response-by-Dorset-County-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that equipment shortages represented a systemic safety issue, noting temporary damage, rapid restoration, and no evidence of compromised patient care.
Verbatim wording from the response “The medical records dated 28 December 2017, indicate that on only three PEEP machines were available across the hospital and that there was difficulty in locating one for use by Mrs Scott. I have investigated this matter and I would advise you that the Trust actually has 6 machines. However, at the time of Mrs Scott’s admission, two machines had been taken out of service as they were physically damaged and were being repaired. This left the Trust with four units. This concern was discussed at a Divisional level and a plan was put in place.” Source location 2018-0172-Response-by-Dorset-County-Hospital-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations