20 May 2026 Isaac Charles ARROWSMITH · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 4 Failure of internal investigations to identify important issues in care View source Lack of a process prompting clinicians to seek further advice about rare conditions View source Lack of a process for sharing learning about clot risk in haemoglobin Rainier disease View source Lack of recognition of clot risk in patients with haemoglobin Rainier disease View source See 1 more concern
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AI-generated summary
Isaac Charles ARROWSMITH · 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
Isaac Arrowsmith, aged 19, died on 2 January 2026 after repeated hospital attendances for chest pain, breathing difficulty and coughing blood, followed by deterioration at home and an unsuccessful resuscitation. The report identified concerns about failure to recognise the clot risk associated with haemoglobin Rainier disease, failure to make a virtual ward referral that would have led to hospital admission, and shortcomings in the Trust’s internal investigation and learning processes.
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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 East Cheshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigations to identify important issues in care
Wider context from the report “1. Lack of knowledge, or recognition of the same, in relation to the risk of a clot when a patient has haemoglobin Rainier disease.
I heard evidence that there was a base level of understanding amongst the emergency department team at the hospital, whereby they knew it was high red blood cells and this increased the risk of clots, but all were falsely reassured by Isaac's almost normal haemoglobin and haematocrit, the recent venesection and that Isaac was on aspirin. I heard evidence that these are false reassurance and I have not heard any evidence from the trust as to how they are going to share this learning. Clearly, all clinicians cannot know the ins and outs of all rare conditions, but I was not assured or any process whereby they are aware that they need to seek further advice. I heard evidence from the Christie Hospital that they are producing an alert card for their patients to give to clinicians in emergency department settings which will assist, but not all patients will be under the Christie or have the alert card in all circumstances.
2. Failure to identify the key causative issue in the Trust's internal investigation or internal processes
The court, and most importantly Isaac's parents, became aware for the first time during the course of the evidence that the referral to the virtual ward had not been made on 31 December, and that had it been, Isaac would not have been accepted and he would have therefore remained in hospital. He would have been in hospital when he deteriorated on 2 January and would therefore have been given full, successful, resuscitation at the time, such that he would not have died when he did. There had been an internal multi disciplinary review tool undertaken which had not identified this issue. This was not a complex issue to identify, and was identified very quickly by the trust's legal team when asked during the course of the evidence. I have received a statement which suggests this was a genuine mistake, made on the back of an assumption. As well as showing lack of critical analysis , it shows a lack of understanding of the virtual ward service. The latter I understand is being addressed by the trust in light of the evidence heard at the inquest but I heard no evidence to suggest that the quality of investigation or analysis is being improved. Whilst the inquest investigation is distinct to the trust investigation, the court is reliant to a large extent on the findings and disclosures made by the trust, taking into account they have a duty of candour and a duty to the court. I am concerned that the investigation process has failed to highlight a very important issue in care , and, if this is the case for other investigations, the opportunity to learn from issues and put in place action to prevent future deaths is lost.
My concern has been compounded by details of an inquest I heard on 18 May, the day before Isaac's inquest, in which questions arose about the trust's internal processes, transparency and learning and the trust legal team is aware of those details. That inquest is not the subject of this report but is additional context to the concern raised.
” 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 Cheshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a process prompting clinicians to seek further advice about rare conditions
Wider context from the report “1. Lack of knowledge, or recognition of the same, in relation to the risk of a clot when a patient has haemoglobin Rainier disease.
I heard evidence that there was a base level of understanding amongst the emergency department team at the hospital, whereby they knew it was high red blood cells and this increased the risk of clots, but all were falsely reassured by Isaac's almost normal haemoglobin and haematocrit, the recent venesection and that Isaac was on aspirin. I heard evidence that these are false reassurance and I have not heard any evidence from the trust as to how they are going to share this learning. Clearly, all clinicians cannot know the ins and outs of all rare conditions, but I was not assured or any process whereby they are aware that they need to seek further advice. I heard evidence from the Christie Hospital that they are producing an alert card for their patients to give to clinicians in emergency department settings which will assist, but not all patients will be under the Christie or have the alert card in all circumstances.
2. Failure to identify the key causative issue in the Trust's internal investigation or internal processes
The court, and most importantly Isaac's parents, became aware for the first time during the course of the evidence that the referral to the virtual ward had not been made on 31 December, and that had it been, Isaac would not have been accepted and he would have therefore remained in hospital. He would have been in hospital when he deteriorated on 2 January and would therefore have been given full, successful, resuscitation at the time, such that he would not have died when he did. There had been an internal multi disciplinary review tool undertaken which had not identified this issue. This was not a complex issue to identify, and was identified very quickly by the trust's legal team when asked during the course of the evidence. I have received a statement which suggests this was a genuine mistake, made on the back of an assumption. As well as showing lack of critical analysis, it shows a lack of understanding of the virtual ward service. The latter I understand is being addressed by the trust in light of the evidence heard at the inquest but I heard no evidence to suggest that the quality of investigation or analysis is being improved. Whilst the inquest investigation is distinct to the trust investigation, the court is reliant to a large extent on the findings and disclosures made by the trust, taking into account they have a duty of candour and a duty to the court. I am concerned that the investigation process has failed to highlight a very important issue in care, and, if this is the case for other investigations, the opportunity to learn from issues and put in place action to prevent future deaths is lost.
My concern has been compounded by details of an inquest I heard on 18 May, the day before Isaac's inquest, in which questions arose about the trust's internal processes, transparency and learning and the trust legal team is aware of those details. That inquest is not the subject of this report but is additional context to the concern raised.
” 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 Cheshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for sharing learning about clot risk in haemoglobin Rainier disease
Wider context from the report “1. Lack of knowledge, or recognition of the same, in relation to the risk of a clot when a patient has haemoglobin Rainier disease.
I heard evidence that there was a base level of understanding amongst the emergency department team at the hospital, whereby they knew it was high red blood cells and this increased the risk of clots, but all were falsely reassured by Isaac's almost normal haemoglobin and haematocrit, the recent venesection and that Isaac was on aspirin. I heard evidence that these are false reassurance and I have not heard any evidence from the trust as to how they are going to share this learning. Clearly, all clinicians cannot know the ins and outs of all rare conditions, but I was not assured or any process whereby they are aware that they need to seek further advice. I heard evidence from the Christie Hospital that they are producing an alert card for their patients to give to clinicians in emergency department settings which will assist, but not all patients will be under the Christie or have the alert card in all circumstances.
2. Failure to identify the key causative issue in the Trust's internal investigation or internal processes
The court, and most importantly Isaac's parents, became aware for the first time during the course of the evidence that the referral to the virtual ward had not been made on 31 December, and that had it been, Isaac would not have been accepted and he would have therefore remained in hospital. He would have been in hospital when he deteriorated on 2 January and would therefore have been given full, successful, resuscitation at the time, such that he would not have died when he did. There had been an internal multi disciplinary review tool undertaken which had not identified this issue. This was not a complex issue to identify, and was identified very quickly by the trust's legal team when asked during the course of the evidence. I have received a statement which suggests this was a genuine mistake, made on the back of an assumption. As well as showing lack of critical analysis, it shows a lack of understanding of the virtual ward service. The latter I understand is being addressed by the trust in light of the evidence heard at the inquest but I heard no evidence to suggest that the quality of investigation or analysis is being improved. Whilst the inquest investigation is distinct to the trust investigation, the court is reliant to a large extent on the findings and disclosures made by the trust, taking into account they have a duty of candour and a duty to the court. I am concerned that the investigation process has failed to highlight a very important issue in care, and, if this is the case for other investigations, the opportunity to learn from issues and put in place action to prevent future deaths is lost.
My concern has been compounded by details of an inquest I heard on 18 May, the day before Isaac's inquest, in which questions arose about the trust's internal processes, transparency and learning and the trust legal team is aware of those details. That inquest is not the subject of this report but is additional context to the concern raised.
” 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 Cheshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of recognition of clot risk in patients with haemoglobin Rainier disease
Wider context from the report “1. Lack of knowledge, or recognition of the same, in relation to the risk of a clot when a patient has haemoglobin Rainier disease.
I heard evidence that there was a base level of understanding amongst the emergency department team at the hospital, whereby they knew it was high red blood cells and this increased the risk of clots, but all were falsely reassured by Isaac's almost normal haemoglobin and haematocrit, the recent venesection and that Isaac was on aspirin. I heard evidence that these are false reassurance and I have not heard any evidence from the trust as to how they are going to share this learning. Clearly, all clinicians cannot know the ins and outs of all rare conditions, but I was not assured or any process whereby they are aware that they need to seek further advice. I heard evidence from the Christie Hospital that they are producing an alert card for their patients to give to clinicians in emergency department settings which will assist, but not all patients will be under the Christie or have the alert card in all circumstances.
2. Failure to identify the key causative issue in the Trust's internal investigation or internal processes
The court, and most importantly Isaac's parents, became aware for the first time during the course of the evidence that the referral to the virtual ward had not been made on 31 December, and that had it been, Isaac would not have been accepted and he would have therefore remained in hospital. He would have been in hospital when he deteriorated on 2 January and would therefore have been given full, successful, resuscitation at the time, such that he would not have died when he did. There had been an internal multi disciplinary review tool undertaken which had not identified this issue. This was not a complex issue to identify, and was identified very quickly by the trust's legal team when asked during the course of the evidence. I have received a statement which suggests this was a genuine mistake, made on the back of an assumption. As well as showing lack of critical analysis, it shows a lack of understanding of the virtual ward service. The latter I understand is being addressed by the trust in light of the evidence heard at the inquest but I heard no evidence to suggest that the quality of investigation or analysis is being improved. Whilst the inquest investigation is distinct to the trust investigation, the court is reliant to a large extent on the findings and disclosures made by the trust, taking into account they have a duty of candour and a duty to the court. I am concerned that the investigation process has failed to highlight a very important issue in care, and, if this is the case for other investigations, the opportunity to learn from issues and put in place action to prevent future deaths is lost.
My concern has been compounded by details of an inquest I heard on 18 May, the day before Isaac's inquest, in which questions arose about the trust's internal processes, transparency and learning and the trust legal team is aware of those details. That inquest is not the subject of this report but is additional context to the concern raised.
” 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 Deliver focused MDT review and After Action Review training through specialty and departmental meetings alongside the established Patient Safety Investigation programme.
Verbatim wording from the response “5. Delivering focused bitesized MDT review and After Action Review training through specialty and departmental meetings to strengthen staff knowledge and promote a consistent approach to reviews, complemented by the Trust’s dedicated full-day Patient Safety Investigation training programme” Source location Response from East Cheshire NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain or access all relevant healthcare records for future patient safety investigations.
Verbatim wording from the response “1. The Trust will obtain and/or gain access to all relevant healthcare records as part of any patient safety investigation to ensure that all relevant information is considered as part of the review” Source location Response from East Cheshire NHS Trust
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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 Enhance the Electronic Patient Record VTE risk assessment with improved information visibility and an additional clotting-versus-bleeding risk prompt.
Verbatim wording from the response “Consequently, the Trust's improvement work has focused on enhancing the functionality of the existing VTE risk assessment within the Electronic Patient Record, including exploration of an additional assessment prompt relating to balancing the individual patient’s clotting and bleeding risk and improving the visibility of VTE-related information within the patient record. This will strengthen system support for clinical decision-making without creating an alert burden. This work is currently being progressed with the Trust's Digital team in conjunction with Mid Cheshire Hospitals NHS Foundation Trust and the Digital Clinical System suppliers, Meditech. A meeting has been scheduled for 17th July 2026 to progress this.” Source location Response from East Cheshire NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the MDT review report template with prompts covering clinical referral processes and other key enquiry areas.
Verbatim wording from the response “4. The MDT review report template is being reviewed and will be updated to include specific prompts relating to the review of clinical referral processes and other key areas of enquiry, which is due to be completed by 20 July 2026” Source location Response from East Cheshire NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a Grand Round session with a consultant haematologist on thrombotic risks associated with uncommon haematological conditions.
Verbatim wording from the response “• Providing a dedicated educational session on the Trust's Grand Round programme, to be delivered jointly with a Consultant Haematologist from The Christie. This session will focus on haematological conditions (including Haemoglobin Rainier Disease) associated with increased thrombotic risk, with learning from Isaac's case being used as an example to illustrate the challenges associated with recognising and managing uncommon but clinically significant risks. This session has been booked for 21 October 2026.” Source location Response from East Cheshire NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add cognitive-bias, diagnostic-overshadowing and clinical-debiasing education to the local undergraduate medical programme.
Verbatim wording from the response “• Incorporating education relating to cognitive bias, diagnostic overshadowing and clinical debiasing strategies within its local undergraduate medical education programme. Isaac's case will be used as a learning example to demonstrate how systems factors, human factors and cognitive processes can influence clinical decision-making, reinforcing the importance of maintaining diagnostic curiosity and seeking specialist advice when managing patients with rare, complex or high-risk conditions. This education will be added to the undergraduate medical education programme by 30 September 2026.” Source location Response from East Cheshire NHS Trust
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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 MDT review quick-reference guide for consistent patient safety reviews.
Verbatim wording from the response “3. Development of an MDT review quick-reference guide to provide staff with clear and consistent guidance on undertaking patient safety MDT reviews, which is due to be completed by 20 July 2026” Source location Response from East Cheshire NHS Trust
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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 standard MDT review commissioning email template specifying required clinical specialities and professional groups.
Verbatim wording from the response “2. The introduction of a standard MDT review commissioning email template which specifies the required clinical specialities and professional groups contributing to each review” Source location Response from East Cheshire NHS Trust
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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 deliver cognitive-bias and debiasing training for Emergency Department clinicians.
Verbatim wording from the response “• Developing and delivering a focused cognitive bias awareness and debiasing session for Emergency Department clinicians. This training will explore the impact of cognitive bias on clinical decision-making, including diagnostic overshadowing, false reassurance and the influence these factors can have on risk assessment, escalation and diagnostic reasoning. This session is aimed to be delivered by 30 September 2026.” Source location Response from East Cheshire NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed MDT review training as an ongoing resource and support clinical leaders to cascade learning across clinical teams.
Verbatim wording from the response “6. Embed MDT review training as an ongoing educational resource and support Clinical Leads, Senior Sisters and Matrons to cascade learning throughout clinical teams” Source location Response from East Cheshire NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the PAUSE Before You Diagnose campaign through staff communications, educational media, posters and Trust-wide screensavers.
Verbatim wording from the response “• Learning article in the staff electronic newsletter – summarising Isaac’s case and the main learning points, linking into the ‘PAUSE before you Diagnose’ initiative. This article was published in the electronic newsletter on 6th July 2026.” Source location Response from East Cheshire NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A broad electronic VTE risk alert cannot be implemented because reliable criteria are difficult to define and alert fatigue could reduce effectiveness.
Verbatim wording from the response “During this review, the feasibility of introducing an electronic alert for patients deemed to be at increased risk of VTE was also explored. However, it was concluded that implementation of such an alert was not feasible. This is due to there being a wide range of medical conditions, comorbidities and clinical factors that may increase an individual's risk of thrombosis, often in varying combinations and with different levels of significance. As a result, it would be challenging to define clear and reliable criteria that would accurately identify all relevant patients who would require an ‘increased risk of VTE’ alert to be added to their EPR.” Source location Response from East Cheshire NHS Trust
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17 Jul 2024 David Nicholas ALMOND · Prevention of Future Deaths report Manchester South
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Concerns raised 3 Failure to provide clinicians with access to GP records across differing IT systems and geographical boundaries View source Failure to recognise the need for follow-up medical review after a negative x-ray View source Failure of differing NHS IT systems to support timely access to GP-record information View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David Nicholas ALMOND · 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 Nicholas Almond was diagnosed with thrombophilia and deep vein thrombosis but was not placed on lifelong anticoagulation. After developing breathlessness that was investigated with an X-ray, he collapsed and was found to have a massive pulmonary embolism, dying in hospital on 5 January 2024. The principal concerns were incomplete access to and recognition of relevant GP records, and failure to arrange appropriate follow-up after the negative X-ray.
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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 East Cheshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clinicians with access to GP records across differing IT systems and geographical boundaries
Wider context from the report “1. The inquest heard evidence that Macclesfield Hospital was part of East Cheshire NHS Trust and served a wide area a significant part of the area served was outside the footprint of the trust for example the High Peak in Derbyshire. The inquest was told that trust doctors were able to access GP records for patient’s registered with GPs in East Cheshire but not patients registered outside this area . The inquest was told there were discussions about how to try to resolve this but no firm steps or progress on this by the Trust .
As a consequence doctors at the hospital were limited in understanding a patient’s history and crucial information was not always fully recognised/available .
” 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 Cheshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the need for follow-up medical review after a negative x-ray
Wider context from the report “3. The inquest heard evidence that in September 2023 when he went to his GP practice he did not see a doctor. It was not recognised by the practitioner who saw him that there may need to be a follow-up appointment or a recommendation that he return to see a doctor should the x ray be negative given his history and presentation.
” 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 Cheshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of differing NHS IT systems to support timely access to GP-record information
Wider context from the report “2. The inquest was told that this inability to access information in GP records was a problem across the NHS due to differing IT systems and caused difficulties in providing effective and timely care to patients .
” 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 Summary Care Record use, access incidents, staff feedback and smart-card support data after implementation.
Verbatim wording from the response “Post-Implementation Review” Source location Response from East Cheshire Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen clinical information gathering by prioritising comprehensive patient histories and asking GPs to review older records when relevant information is unavailable.
Verbatim wording from the response “• Commitment to Professional Curiosity: Moving forward, the doctor has committed to demonstrating greater professional curiosity. This includes proactively asking the GP to review older records when we do not have access to the relevant information, ensuring that decisions are based on the most complete information available.” Source location Response from East Cheshire Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement Summary Care Record access for relevant clinical and discharge staff, including smart cards, training, induction, departmental support and troubleshooting.
Verbatim wording from the response “Implementation Plan” Source location Response from East Cheshire Trust
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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 is addressing differing NHS IT systems and GP record access, so the Trust will not address this matter further.
Verbatim wording from the response “The Trust understands that NHS England will be addressing this matter in detail within their response to the PFD and therefore proposes not to address this further.” Source location Response from East Cheshire Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GP practice’s provider, gtd healthcare, is responsible for responding to concerns about that primary care contact.
Verbatim wording from the response “As this concern relates to Mr Almond’s clinical contact with his GP practice and not to care delivered by East Cheshire NHS Trust, we have sought the input of the gtd healthcare for the GP practice to provide the response that follows:” Source location Response from East Cheshire Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GP practice contact concerned care outside the Trust’s remit because it was not delivered by East Cheshire NHS Trust.
Verbatim wording from the response “As this concern relates to Mr Almond’s clinical contact with his GP practice and not to care delivered by East Cheshire NHS Trust, we have sought the input of the gtd healthcare for the GP practice to provide the response that follows:” Source location Response from East Cheshire Trust
Open published response
8 Oct 2013 Anthony Bernard McCormick · Prevention of Future Deaths report Manchester City
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Concerns raised 5 Failure to provide continuous appropriate antibiotic therapy View source Failure to make a timely and appropriate specialist Hepato-Biliary referral View source Failure of senior clinical review to recognise seriousness and plan urgent treatment View source Failure to provide urgent admission and further investigation after significant test results View source Failures in communication of significant clinical information 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.
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AI-generated summary
Anthony Bernard McCormick · 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
Anthony Bernard McCormick was admitted to hospital with gastrointestinal symptoms, vomiting, lethargy, fever and rigors, and was later found to have liver abscesses and gallstones. He underwent surgery but developed pneumonia and sepsis and died on 31 May 2011; the post-mortem found extensive empyema and sepsis. Concerns included delays in urgent admission, diagnosis, specialist referral and surgery, failures in communication and clinical review, and gaps in appropriate antibiotic treatment.
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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 East Cheshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuous appropriate antibiotic therapy
Wider context from the report “5. Throughout the course of his clinical care at Macclesfield Hospital there was a failure to ensure that he consistently received appropriate antibiotic therapy without avoidable gaps in treatment .
6. The deceased had not been referred in a timely and appropriate manner for the Cholecystectomy following the HPB MDT on 9 March 2011 and was not provided with appropriate antibiotic cover to ensure resolution of his liver abscesses
” 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 Cheshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make a timely and appropriate specialist Hepato-Biliary referral
Wider context from the report “3. Upon receiving advice about the need for a Cholecystectomy after the HPB MDT on 9 March 2011 there was a significant failure to ensure that a timely and appropriate referral was made to a specialist Hepato-Biliary surgeon .
4. Requesting the GP to make a formal referral at that stage was inappropriate and caused significant further delay in appropriate treatment. His care was being led by a senior and experienced Consultant.
” 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 Cheshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of senior clinical review to recognise seriousness and plan urgent treatment
Wider context from the report “1. When the results of the blood tests taken at Macclesfield Hospital on 27 January 2011 were received this should have resulted in an urgent admission to hospital and further investigations undertaken to establish the source of the symptoms. This did not happen and suggests failures in communication and senior clinical review and appreciation of the significance of the presenting symptoms .
2. There was a significant failure to appreciate the seriousness of the condition, the need for urgent treatment and associated raised mortality risks upon the receipt of the results of the CT scan on 28 February 2011 showing the presence of multiple liver abscesses and gallstones. These are all factors which it would be reasonable to expect senior clinicians to appreciate and plan accordingly .
” 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 Cheshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide urgent admission and further investigation after significant test results
Wider context from the report “1. When the results of the blood tests taken at Macclesfield Hospital on 27 January 2011 were received this should have resulted in an urgent admission to hospital and further investigations undertaken to establish the source of the symptoms . This did not happen and suggests failures in communication and senior clinical review and appreciation of the significance of the presenting symptoms.
2. There was a significant failure to appreciate the seriousness of the condition, the need for urgent treatment and associated raised mortality risks upon the receipt of the results of the CT scan on 28 February 2011 showing the presence of multiple liver abscesses and gallstones. These are all factors which it would be reasonable to expect senior clinicians to appreciate and plan accordingly.
” 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 Cheshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failures in communication of significant clinical information
Wider context from the report “1. When the results of the blood tests taken at Macclesfield Hospital on 27 January 2011 were received this should have resulted in an urgent admission to hospital and further investigations undertaken to establish the source of the symptoms. This did not happen and suggests failures in communication and senior clinical review and appreciation of the significance of the presenting symptoms.
2. There was a significant failure to appreciate the seriousness of the condition, the need for urgent treatment and associated raised mortality risks upon the receipt of the results of the CT scan on 28 February 2011 showing the presence of multiple liver abscesses and gallstones. These are all factors which it would be reasonable to expect senior clinicians to appreciate and plan accordingly.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations