Recipient

East and North Hertfordshire Teaching NHS Trust

First report 10 Aug 2015•Latest report 15 Feb 2022

Recipient record

Reports, concerns and published responses

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

Reports: 4
Published responses: 100%
Concerns addressed: 9
Stated actions: 18

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.

100%published responses found

18stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from East and North Hertfordshire Teaching NHS Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

15 Feb2022
Hertfordshire
Concerns raised4
1. Failure to calculate NEWS accurately
2. Poor completion of clinical documentation
3. Failure to escalate care appropriately in ICU
1. Failure to document NEWS accurately
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

David 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

David Clark died at Lister Hospital on 5 January 2020 after being readmitted in a drowsy state and in respiratory failure. The report identified concerns that his worsening condition was not accurately assessed or escalated appropriately, NEWS were not calculated or documented accurately, and his treatment was poorly documented. It was unclear whether these matters contributed to his death.

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 East and North Hertfordshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to calculate NEWS accurately
Wider context from the report
“(2) That NEWS were not being calculated or documented accurately. ”
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 East and North Hertfordshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Poor completion of clinical documentation
Wider context from the report
“(3) That documentation, more generally, was poorly completed. ”
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 East and North Hertfordshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to escalate care appropriately in ICU
Wider context from the report
“(1) That care was not escalated appropriately in ICU despite being fully staffed. ”
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 East and North Hertfordshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to document NEWS accurately
Wider context from the report
“(2) That NEWS were not being calculated or documented accurately. ”
Open source report
15 Dec2020
Hertfordshire
Concerns raised4
1. Failure to establish that training prevents recurrence of the same situation
2. Use of wrong guidelines for foetal heart rate monitoring in labour
3. Failure in basic medical care for foetal heart rate monitoring and management during labour
1. Failure of serious incident investigation to determine directly responsible factors
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Procure six standardised CTG machines that record maternal pulse and place the work under capital-committee and risk-register oversight.
  Stated in progress
2. Action
  Employ a full-time fetal monitoring specialist midwife to provide guidance, teaching, CTG review and education leadership.
  Stated completed
3. Action
  Review emerging Ockenden Report findings and recommendations relevant to CTG monitoring.
  Stated completed
1. Action
  Establish a standard operating procedure for LMNS oversight of serious incident investigations and action plans.
  Stated completed
2. Action
  Introduce a CTG-machine sticker requiring two independent maternal-pulse checks and signatures after transfer from MLU to CLU.
  Stated in progress
3. Action
  Obtain future independent clinical opinions under formal terms of reference.
  Stated planned
4. Action
  Roll out an intermittent auscultation and escalation competency package with case scenarios, small-group and annual training, competency assessment and pass-rate auditing.
  Stated in progress
5. Action
  Develop and implement planned CTG interpretation and escalation actions to establish a robust process.
  Stated in progress
6. Action
  Enhance fetal monitoring training, including second-stage labour interpretation, maternal-pulse recognition, human factors and incident learning.
  Stated in progress
Respondent positions 1
1. Position
  The Department of Health and Social Care will respond to why 100 maternity units follow the new fetal heart rate monitoring guidelines.
  Redirects responsibility
AI-generated summary

Eddie Coffey · 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

Eddie Coffey was born at Lister Hospital in a poor state, with a low heart rate and symptoms of hypoxia, and required resuscitation before transfer to neonatal intensive care. He died at Luton & Dunstable Hospital from perinatal asphyxia. Inquest evidence identified gross failures in monitoring and managing the foetal heart rate during labour, and raised concerns about whether the same situation could recur and whether other maternity units were following incorrect guidelines.

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 East and North Hertfordshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to establish that training prevents recurrence of the same situation
Wider context from the report
“(4) It was not clear from the inquest that, despite training implemented by the Trust since the death, that the same situation would not arise 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 East and North Hertfordshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Use of wrong guidelines for foetal heart rate monitoring in labour
Wider context from the report
“(5) The Evidence was given at the inquest by an independent Consultant Obstetrician that 100 maternity units in the country are following the wrong guidelines in relation to managing foetal heart rate monitoring in labour. ”
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 East and North Hertfordshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure in basic medical care for foetal heart rate monitoring and management during labour
Wider context from the report
“(2) Evidence was given at the inquest by a Consultant Obstetrician from Lister Hospital that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure Eddie Coffey might have survived. (3) Evidence was given at the inquest by an independent Consultant Obstetrician that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure Eddie Coffey would more than likely have survived. ”
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 East and North Hertfordshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure of serious incident investigation to determine directly responsible factors
Wider context from the report
“(1) The Serious Incident Report prepared on behalf of East and North Hertfordshire NHS Trust concluded that the Investigation was unable to determine the factors that were directly responsible for the death of baby Eddie Coffey. This conclusion was directly contradicted by evidence at the inquest. ”
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
Procure six standardised CTG machines that record maternal pulse and place the work under capital-committee and risk-register oversight.

Verbatim wording from the response
“Notwithstanding the training that has been implemented already at the Trust, it is accepted that CTG technology is not straightforward. This has led to a review being undertaken of the CTG machines currently in use within the Trust. As a department, Maternity are working towards standardising equipment in line with best practice. Review of the CTG machines currently in use has identified that 6 new machines are required which would then mean that all of the machines in use are the same and all would record maternal pulse on the CTG trace. Further work towards the procurement of these machines is ongoing and being reviewed by our Capital Equipment Committee. This issue will be added to the risk register which will ensure oversight and enable clear monitoring on a regular basis.”

Source location
2020-0287-Response-from-Lister-Hospital-Redacted
Page 2 · response
Published 7 January 2021
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 full-time fetal monitoring specialist midwife to provide guidance, teaching, CTG review and education leadership.

Verbatim wording from the response
“In order to mitigate against this risk, the Trust is committed to enhancing our already well established Fetal Monitoring training and in particular enhancing the training provided to staff with regards to the second stage of labour. The importance of this issue is highlighted in every Fetal Monitoring lecture as maternal pulse features and characteristics are included as well as being included in an element of the Human Factors training that is given. The intended impact of this is to ignite professional curiosity and to encourage clinicians to actively seek out to exclude maternal pulse. Furthermore, since 20 January 2020 the trust has employed a full time fetal monitoring specialist midwife for 12 months.”

Source location
2020-0287-Response-from-Lister-Hospital-Redacted
Page 2 · response
Published 7 January 2021
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 emerging Ockenden Report findings and recommendations relevant to CTG monitoring.

Verbatim wording from the response
“We have also reviewed the emerging findings and recommendations from the first Ockenden Report in their ongoing review of Maternity Services at Shrewsbury and Telford Hospital Trust published in December 2020. As you may already be aware, one action in this report relates”

Source location
2020-0287-Response-from-Lister-Hospital-Redacted
Page 2 · response
Published 7 January 2021
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
Establish a standard operating procedure for LMNS oversight of serious incident investigations and action plans.

Verbatim wording from the response
“the Directors of Midwifery and the LMNS Programme Lead have agreed a standard operating procedure for LMNS oversight of SI investigations and action plans going forward.”

Source location
2020-0287-Response-from-Lister-Hospital-Redacted
Page 2 · response
Published 7 January 2021
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 CTG-machine sticker requiring two independent maternal-pulse checks and signatures after transfer from MLU to CLU.

Verbatim wording from the response
“Moreover, in terms of immediate practical steps taken, we are in the process of producing a visual sticker that will go at the front of a CTG machine after a woman is transferred from MLU to CLU. This sticker will include a box for two individuals to check and sign that they have independently palpated maternal pulse. This process will be in place by the end of February 2021.”

Source location
2020-0287-Response-from-Lister-Hospital-Redacted
Page 2 · response
Published 7 January 2021
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 future independent clinical opinions under formal terms of reference.

Verbatim wording from the response
“When obtaining an independent third-party or independent clinical opinion in the future the trust will ensure this is done on a more formal basis with clear terms of reference.”

Source location
2020-0287-Response-from-Lister-Hospital-Redacted
Page 1 · response
Published 7 January 2021
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 an intermittent auscultation and escalation competency package with case scenarios, small-group and annual training, competency assessment and pass-rate auditing.

Verbatim wording from the response
“In response to your fourth point, actions have been developed to further strengthen the training in relation to second stage fetal monitoring interpretation. A second stage training update was delivered on 19 January 2021 which focussed on fetal monitoring and recognising the signs to differentiate between maternal pulse and fetal heart rate, highlighting learning from themes and incidents. Further sessions have been planned in this regard. An Intermittent Auscultation and escalation competency package, using added case scenarios including small group sessions and annual training, is being rolled out to the Midwifery-Led-Unit (MLU) midwives supported by a plan to role this out to all midwives. This will include a competency - based assessment and a requirement to record pass rates for ongoing auditing and assurance.”

Source location
2020-0287-Response-from-Lister-Hospital-Redacted
Page 2 · response
Published 7 January 2021
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 planned CTG interpretation and escalation actions to establish a robust process.

Verbatim wording from the response
“to CTG monitoring with a number of elements in relation to the management of CTG interpretation and escalation. We have planned for a number of actions going forward in order to ensure that we have a robust process in place in respect of these. Please see the attached excel spreadsheet for full sight of the CTG action plan, some of which are detailed above and the work is ongoing.”

Source location
2020-0287-Response-from-Lister-Hospital-Redacted
Page 3 · response
Published 7 January 2021
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
Enhance fetal monitoring training, including second-stage labour interpretation, maternal-pulse recognition, human factors and incident learning.

Verbatim wording from the response
“In order to mitigate against this risk, the Trust is committed to enhancing our already well established Fetal Monitoring training and in particular enhancing the training provided to staff with regards to the second stage of labour. The importance of this issue is highlighted in every Fetal Monitoring lecture as maternal pulse features and characteristics are included as well as being included in an element of the Human Factors training that is given. The intended impact of this is to ignite professional curiosity and to encourage clinicians to actively seek out to exclude maternal pulse. Furthermore, since 20 January 2020 the trust has employed a full time fetal monitoring specialist midwife for 12 months.”

Source location
2020-0287-Response-from-Lister-Hospital-Redacted
Page 2 · response
Published 7 January 2021
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 Department of Health and Social Care will respond to why 100 maternity units follow the new fetal heart rate monitoring guidelines.

Verbatim wording from the response
“Lastly, I note your area of concern relating to why 100 maternity units in the country are following the new guidelines in relation to managing fetal heart rate monitoring following the evidence you heard from ████████ at the Inquest. I am aware that the Department of Health and Social Care will be responding to you on this point however I hope the contents of this letter demonstrates the relevant actions that the Trust have taken in relation to this.”

Source location
2020-0287-Response-from-Lister-Hospital-Redacted
Page 3 · response
Published 7 January 2021
Open published response
5 Sep2019
Hertfordshire
Concerns raised1
1. Failure to identify serious injuries following road traffic collisions
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review the care provided on 4 May 2018.
  Status unclear
Respondent positions 1
1. Position
  Clinical findings did not require head or forearm imaging; assessment and national guidance supported no further investigation.
  Disputes the concern
AI-generated summary

Tillie SPENCER-ADAMS · 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

Tillie Spencer-Adams was found unresponsive in her mother's bed on 18 June 2018 and could not be resuscitated. The medical cause of death was unascertained, with the inquest concluding Sudden Unexpected Death in Infancy. The report identified concern that injuries potentially sustained in a road traffic collision, including fractures and head injuries, may have been overlooked when she attended hospital on 4 May 2018.

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 East and North Hertfordshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to identify serious injuries following road traffic collisions
Wider context from the report
“(1) On the 4/5/18 the deceased attended the Lister Hospital following a road traffic collision in which she is likely to have suffered serious injuries (fractures and head injuries) which appear to have been overlooked. ”
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
Review the care provided on 4 May 2018.

Verbatim wording from the response
“The contents of your letter were of grave concern to me and therefore I asked ████████ Clinical Director for Paediatrics, to review the care provided when Tillie attended on 4th May 2018.”

Source location
2019-0356-Response-by-East-and-North-Hertfordshire-NHS-Trust
Page 1 · response
Published 22 November 2019
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
Clinical findings did not require head or forearm imaging; assessment and national guidance supported no further investigation.

Verbatim wording from the response
“Whilst the triage nurse in ED noted a red mark on Tillie’s head, this was not observed by either the Paediatric doctors who reviewed her, nor any of the Paediatric nurses. In addition, Tillie did not exhibit any red-flag symptoms indicative of a head injury. Thus, in line with NICE Guidance, there was no indication to perform a CT head scan. Equally there were no external signs of any injury to her right forearm, nor did Tillie appear to be in any discomfort whilst in ED or the Paediatric unit. She did not require any analgesia and the medical records indicate that she was settled throughout.”

Source location
2019-0356-Response-by-East-and-North-Hertfordshire-NHS-Trust
Page 2 · response
Published 22 November 2019
Open published response
10 Aug2015
Bedfordshire and Luton
Concerns raised2
1. Failure to implement thromboprophylaxis guidance for patients requiring temporary limb immobilisation
2. Lack of a protocol for assessing patients attending the Plaster Room
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review current VTE guidance against NICE and Royal College of Emergency Medicine recommendations.
  Stated in progress
2. Action
  Issue interim guidance requiring plaster-room technicians and fracture-clinic staff to obtain medical review in specified circumstances.
  Stated completed
AI-generated summary

LORRAINE JOYCE BIRD · 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

Lorraine Joyce Bird fractured her ankle after a fall and later attended a plaster room with numbness in her foot. The report identifies concerns that a developing deep vein thrombosis was not recognised or medically reviewed, that there was no adequate assessment protocol, and that she had not received low molecular weight heparin. The inquest concluded that this resulted in a lost opportunity for further treatment and that she died on 13 September 2014.

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 East and North Hertfordshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to implement thromboprophylaxis guidance for patients requiring temporary limb immobilisation
Wider context from the report
“(1) In September 2013 The College of Emergency Medicine issued a “Guideline for the use of Thromboprophylaxis in Ambulatory Patients Requiring Temporary Limb Immobilisation”. This recommends the use of Low Molecular Weight Heparin (LMWH) to be used until the plaster is removed. (2) When Lorraine Bird attended Colchester Hospital she was not given LMWH. The hospital had not yet introduced the Guideline, although they were in the process of trying to agree the funding to enable them to adopt 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 East and North Hertfordshire Teaching NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of a protocol for assessing patients attending the Plaster Room
Wider context from the report
“(2) There appears to be a complete lack of a Protocol for the assessment of patients who attend for treatment at the Plaster Room. ”
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
Review current VTE guidance against NICE and Royal College of Emergency Medicine recommendations.

Verbatim wording from the response
“Prior to this incident there was no written guidance available to the Plaster room technicians. Current venous thromboembolic (VTE) guidance (incorporating NICE and Royal College of Emergency Medicine recommendations) is under review with full compliance with all recommendation currently anticipated for March 2016. Pending approval and ratification of this new overarching policy, the Clinical Director for Orthopaedics has issued immediate interim guidance to all plaster room technicians and fracture clinic medical staff.”

Source location
2015-0315-Response-by-East-North-Hertfordshire-NHS-Trust
Page 1 · response
Published 10 August 2015
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
Issue interim guidance requiring plaster-room technicians and fracture-clinic staff to obtain medical review in specified circumstances.

Verbatim wording from the response
“Prior to this incident there was no written guidance available to the Plaster room technicians. Current venous thromboembolic (VTE) guidance (incorporating NICE and Royal College of Emergency Medicine recommendations) is under review with full compliance with all recommendation currently anticipated for March 2016. Pending approval and ratification of this new overarching policy, the Clinical Director for Orthopaedics has issued immediate interim guidance to all plaster room technicians and fracture clinic medical staff.”

Source location
2015-0315-Response-by-East-North-Hertfordshire-NHS-Trust
Page 1 · response
Published 10 August 2015
Open published response

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 raised4

Failure to calculate NEWS accurately

Poor completion of clinical documentation

Failure to escalate care appropriately in ICU

Failure to document NEWS accurately

Concerns raised4

Failure to establish that training prevents recurrence of the same situation

Use of wrong guidelines for foetal heart rate monitoring in labour

Failure in basic medical care for foetal heart rate monitoring and management during labour

Failure of serious incident investigation to determine directly responsible factors

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.9

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Concerns raised1

Failure to identify serious injuries following road traffic collisions

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

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Concerns raised2

Failure to implement thromboprophylaxis guidance for patients requiring temporary limb immobilisation

Lack of a protocol for assessing patients attending the Plaster Room

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.2

Actions described in response 9

Respondent positions 1

Actions described in response 1

Respondent positions 1

Actions described in response 2