25 Jun 2026 KERRY TERESA SINGH · Prevention of Future Deaths report City of London
View report summary
Concerns raised 6 Lack of a system for checking access to and reading of important test results View source Lack of timely tertiary-centre involvement in care planning for patients requiring pacemaker lead extraction View source Lack of a system for independent investigation and review of serious clinical omissions View source Lack of a system for involving patients in decisions about the timing of required procedures View source Lack of a system for checking completion of important clinical tasks and referrals View source Insufficient protected time and unmanaged clinical communications for completion of important tasks View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 7
Action
Implement the revised Devices MDT governance documents, including referral criteria, clinical reasoning, patient involvement, escalation and action-accountability requirements.
Stated completedThe respondent said that this action was complete when they made their response on 21 August 2026. View source
Action
Prepare a business case and assess internal resources for funding a dedicated Cardiology MDT Coordinator role.
Stated in progressThe respondent said that this action was in progress when they made their response on 21 August 2026. View source
Action
Maintain a centralised Devices MDT action log with named responsibility, completion dates, status tracking and escalation of outstanding actions.
Stated completedThe respondent said that this action was complete when they made their response on 21 August 2026. View source
Action
Apply the strengthened MDT governance model, where appropriate, to other Cardiology Service MDTs.
Stated plannedThe respondent said that this action was planned when they made their response on 21 August 2026. View source
Action
Reinforce reporting of patient-safety concerns identified during inquest preparation or other reviews, share relevant documents and regularly review inquest cases through the Patient Safety Team.
Stated in progressThe respondent said that this action was in progress when they made their response on 21 August 2026. View source
Action
Review implementation of the revised abnormal-results escalation process and compliance with completion of Devices MDT actions through governance arrangements.
Stated plannedThe respondent said that this action was planned when they made their response on 21 August 2026. View source
Action
Revise the abnormal-results process to categorise urgency, specify response routes and timeframes, escalate unacknowledged findings, and document communication and clinical action.
Stated in progressThe respondent said that this action was in progress when they made their response on 21 August 2026. View source See 4 more actions
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AI-generated summary
KERRY TERESA SINGH · 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
Kerry Teresa Singh died on 14 July 2025 after urgent extraction of a failing pacemaker lead caused a tear to the superior vena cava, severe bleeding and unsuccessful resuscitation. The report identified delays in involving a tertiary centre, failures to review a critical test result and complete a referral, inadequate systems for patient involvement and task monitoring, and a lack of internal investigation or review.
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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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for checking access to and reading of important test results
Wider context from the report “5. The Deceased’s critical test result, which was available from the 31st December 2024, was not accessed by the responsible consultant until March 2025. Further, the decision made subsequently, on the 3rd April 2025, to refer for lead extraction was not acted upon and no referral was made. It is not appropriate for concerns about the clinician to be addressed by means of this PFD Report. However, the failures raise concern also for the systems in place in the William Harvey Hospital. First, in evidence, the clinician suggested that she had not been provided by the Trust with sufficient time in which to perform these tasks and that she was overwhelmed by receiving an unnecessary number of communications. Secondly, I was told that there was no system in place to check that test results have been accessed and read or to alert clinicians to test results which had not been accessed and read , whether through IT alerts or otherwise. Thirdly, it seems that there is no system in place to check that important tasks (such as making a patient referral) have been performed and/or to identify when they have not been performed within a reasonable period.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of timely tertiary-centre involvement in care planning for patients requiring pacemaker lead extraction
Wider context from the report “1. Although the need for pacemaker lead extraction at some point was recognised by 2019 at the latest, and although the procedure would necessarily be performed in a tertiary centre, no tertiary centre was consulted or involved in relevant care planning prior to the Deceased’s death ; there was no such involvement in 2021, when a decision was made to change the pacemaker battery but not the leads, and there was no such involvement subsequently, as the Deceased’s condition deteriorated.
2. The evidence I heard from St. Bartholomew’s Hospital was that it is important that the tertiary centre is aware of such patients at any early stage , as this provides an opportunity for the specialist team to understand fully the patient’s precise situation, and to plan for an elective procedure to be performed in a timely manner. I heard that the team at St. Bartholomew’s Hospital has such early involvement with the hospitals from which referrals are routinely received (which does not include the William Harvey Hospital).
3. I am concerned that the lack of timely involvement of the relevant tertiary centre in care planning may result in future deaths.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for independent investigation and review of serious clinical omissions
Wider context from the report “6. Given the seriousness of the omissions by the responsible consultant, which were apparent from her witness statement provided to me in advance of the inquest, I am concerned that the William Harvey Hospital and the Trust did not undertake, prior to the inquest, any internal investigation or review of its care and management of the Deceased , whether by means of a mortality review or otherwise.
7. I am concerned that an absence of a system to ensure that serious omissions are investigated and reviewed, independently of the inquest process , will result in failures to make necessary improvements for patient safety and thereby the risk of future deaths.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for involving patients in decisions about the timing of required procedures
Wider context from the report “4. Further, at the inquest, concern was expressed by the Deceased’s family that she was not fully informed and consulted on the question of when the required lead extraction procedure should be performed. There was clear evidence that by late 2024, her condition had deteriorated significantly and that she later expressed her wish to undergo the procedure as soon as possible. There does not appear to be any system in place to ensure that, when it is recognised that a procedure will be needed at some point, the patient is fully involved in the decision making as to when it is performed .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for checking completion of important clinical tasks and referrals
Wider context from the report “5. The Deceased’s critical test result, which was available from the 31st December 2024, was not accessed by the responsible consultant until March 2025. Further, the decision made subsequently, on the 3rd April 2025, to refer for lead extraction was not acted upon and no referral was made. It is not appropriate for concerns about the clinician to be addressed by means of this PFD Report. However, the failures raise concern also for the systems in place in the William Harvey Hospital. First, in evidence, the clinician suggested that she had not been provided by the Trust with sufficient time in which to perform these tasks and that she was overwhelmed by receiving an unnecessary number of communications. Secondly, I was told that there was no system in place to check that test results have been accessed and read or to alert clinicians to test results which had not been accessed and read, whether through IT alerts or otherwise. Thirdly, it seems that there is no system in place to check that important tasks (such as making a patient referral) have been performed and/or to identify when they have not been performed within a reasonable period .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient protected time and unmanaged clinical communications for completion of important tasks
Wider context from the report “5. The Deceased’s critical test result, which was available from the 31st December 2024, was not accessed by the responsible consultant until March 2025. Further, the decision made subsequently, on the 3rd April 2025, to refer for lead extraction was not acted upon and no referral was made. It is not appropriate for concerns about the clinician to be addressed by means of this PFD Report. However, the failures raise concern also for the systems in place in the William Harvey Hospital. First, in evidence, the clinician suggested that she had not been provided by the Trust with sufficient time in which to perform these tasks and that she was overwhelmed by receiving an unnecessary number of communications . Secondly, I was told that there was no system in place to check that test results have been accessed and read or to alert clinicians to test results which had not been accessed and read, whether through IT alerts or otherwise. Thirdly, it seems that there is no system in place to check that important tasks (such as making a patient referral) have been performed and/or to identify when they have not been performed within a reasonable period.
” 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 Implement the revised Devices MDT governance documents, including referral criteria, clinical reasoning, patient involvement, escalation and action-accountability requirements.
Verbatim wording from the response “Following the inquest into Mrs Singh’s death, the Terms of Reference for the Devices MDT were formally reviewed and ratified. A Standard Operating Procedure (“SOP”) has also been developed and implemented.” Source location Response from East Kent Hospitals University NHS Foundation 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 Prepare a business case and assess internal resources for funding a dedicated Cardiology MDT Coordinator role.
Verbatim wording from the response “The service has developed a job description for a dedicated Cardiology MDT Coordinator. The proposed role would support the administration of Cardiology MDTs, maintain action logs, monitor completion of agreed actions, ensure that outcomes are uploaded to the electronic patient record and support audit of compliance with MDT processes.” Source location Response from East Kent Hospitals University NHS Foundation 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 Maintain a centralised Devices MDT action log with named responsibility, completion dates, status tracking and escalation of outstanding actions.
Verbatim wording from the response “Although actions arising from MDT discussions were historically recorded on individual referral documentation, the Cardiology Service has now introduced a centralised MDT action log.” Source location Response from East Kent Hospitals University NHS Foundation 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 Apply the strengthened MDT governance model, where appropriate, to other Cardiology Service MDTs.
Verbatim wording from the response “The revised governance documents define the purpose and scope of the MDT, responsibilities of attendees, referral criteria, arrangements for recording clinical reasoning and communicating outcomes, circumstances in which tertiary advice should be sought, and the process for allocating, monitoring and escalating MDT actions.” Source location Response from East Kent Hospitals University NHS Foundation 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 Reinforce reporting of patient-safety concerns identified during inquest preparation or other reviews, share relevant documents and regularly review inquest cases through the Patient Safety Team.
Verbatim wording from the response “The Trust Patient Safety Incident Response Policy and Plan already recognise that inquest review and preparation may identify patient-safety issues and learning. In order to strengthen the practical application of this requirement, the Trust is reinforcing the expectation that staff, including clinical and legal services, report patient-safety concerns identified during inquest preparation or other review processes so that they can be considered through the appropriate governance route and a proportionate learning response determined. Relevant documents, including witness statements, where appropriate, will be made available within the risk-management system to support patient-safety review, and a list of inquest cases will be shared with and reviewed regularly by the Patient Safety Team.” Source location Response from East Kent Hospitals University NHS Foundation 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 Review implementation of the revised abnormal-results escalation process and compliance with completion of Devices MDT actions through governance arrangements.
Verbatim wording from the response “Actions agreed through the Devices MDT are now recorded on a central action log, with a named responsible individual and target completion date. Outstanding or overdue actions are reviewed through the MDT process and escalated where necessary. This includes tertiary-centre referrals, investigations, consultant review, changes to follow-up and communication with patients. Where tertiary referral is agreed, completion is confirmed by evidence that the referral has been submitted and recorded.” Source location Response from East Kent Hospitals University NHS Foundation 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 Revise the abnormal-results process to categorise urgency, specify response routes and timeframes, escalate unacknowledged findings, and document communication and clinical action.
Verbatim wording from the response “The Trust recognises that the reliable management of abnormal results and important clinical actions requires a closed-loop process. Simply sending a result or communication to a named clinician does not, by itself, provide assurance that the information has been reviewed, acknowledged and acted upon.” Source location Response from East Kent Hospitals University NHS Foundation 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 specialist extraction centre, in consultation with the patient, makes the final decision about whether and when lead extraction occurs.
Verbatim wording from the response “The final decision about whether and when to undertake extraction is made by the specialist extraction centre in consultation with the patient. The local Cardiology Service is, however, responsible for ensuring that the patient’s concerns and preferences are heard, documented and considered when determining whether specialist advice or referral is required.” Source location Response from East Kent Hospitals University NHS Foundation Trust
Open published response
9 Jan 2026 Sarah Heaver · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 4 Failure to undertake structured neurological observations View source Failure to undertake appropriate neurological investigation View source Unavailability of psychiatric input after acute hospital discharge View source Inconsistent, unreliable and incomplete medical records View source See 1 more concern
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
Sarah Heaver · 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
Sarah Heaver, aged 59, was found unconscious at home on 21 May 2024 and later entered the sea at Whitstable in a deliberate attempt to end her life; she was pronounced deceased in hospital on 27 May 2024. Concerns included the absence of a CT head scan and structured neurological observations after presentation with a very low GCS, inconsistent and incomplete medical records, and gaps in access to psychiatric input after discharge from acute hospital care.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake structured neurological observations
Wider context from the report “(2) I am concerned that no structured neurological observations were undertaken on a patient presenting with such a low GCS, risking deterioration being missed.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake appropriate neurological investigation
Wider context from the report “(1) Sarah Heaver was admitted with a GCS of 3, later improving to between 5–8/15, with unknown downtime and an unclear history. A CT head scan was indicated and not undertaken. I am concerned that appropriate neurological investigation was not carried out .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of psychiatric input after acute hospital discharge
Wider context from the report “(4) I am concerned that patients are discharged from acute hospital settings on the understanding that they will receive psychiatric input equivalent to hospital admission, only for it to later become apparent that there is no access to a psychiatrist or prescriber for several days , particularly over bank holiday periods .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent, unreliable and incomplete medical records
Wider context from the report “(3) Throughout this investigation I was presented with inconsistent, unreliable and incomplete medical records . This significantly hindered my ability to investigate the death and creates a risk of future patient harm.
” 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 Develop and submit a revised digital deteriorating-patient pathway for testing, including automatic GCS access and mandatory completion where indicated.
Verbatim wording from the response “parameter is entered (i.e. any response other than “Alert”), the system prompts the user to indicate whether a Glasgow Coma Scale (GCS) assessment is required. However, even when a clinician confirms that a GCS assessment is clinically indicated, completion of the GCS remains non-mandatory, and observations may be submitted without this assessment being recorded. Furthermore, the current configuration requires the clinician to manually locate and complete the GCS assessment further down within the flowsheet, which introduces risk of omission during time-critical situations.” Source location Response from East Kent Hospitals University NHS Foundation 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 Present documentation standards and accurate-recording expectations during junior doctor Trust induction.
Verbatim wording from the response “As an aside, this case was discussed in the Trust’s Mortality meeting and the general consensus was that management was appropriate in accordance with NICE guidance. The inquest did highlight issues with documentation, it was not of an optimal standard and not in line with GMC Good Medical Practice guidance. We have presented this to the Junior Doctors on their trust induction as well to ensure that notes are accurately recorded and not ‘copy and pasted’.” Source location Response from East Kent Hospitals University NHS Foundation 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 Present revised neurological assessment and escalation standards at Urgent, Emergency, and Acute Medicine governance meetings.
Verbatim wording from the response “• Governance Meetings
The revised policy will be formally presented at Urgent, Emergency, and Acute Medicine governance meetings by the Consultant team. This ensures that clinical expectations and gold-standard practice in the assessment, escalation, and management of patients with reduced or fluctuating GCS are clearly communicated and understood across relevant specialties.” Source location Response from East Kent Hospitals University NHS Foundation 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 Update the Vital Signs Policy to require escalation for neurological deterioration and fifteen-minute then thirty-minute observations during Naloxone infusions.
Verbatim wording from the response “In addition, as mentioned in the Trust’s letter in August 2025, the Vital Signs Policy has been reviewed and updated effective from November 2025. This revision incorporates specific learning identified from the incident involving Mrs Heaver and reflects the Trust’s commitment to continuous improvement, education, and the embedding of best practice into clinical governance frameworks.” Source location Response from East Kent Hospitals University NHS Foundation 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 Implement improvements to electronic documentation of neurological observations.
Verbatim wording from the response “The Trust’s letter in August 2025 showed how Mrs Heaver’s GCS improved rapidly during transport (after the bolus of Naloxone) and then upon admission to hospital. However, review of the notes identified the need for improved documentation of neurological observations. The case identified the need for standardised and frequent GCS documentation. The Trust’s Deteriorating Patient Lead Nurse has reviewed the notes and implemented improvements to the Trust’s electronic documentation system.” Source location Response from East Kent Hospitals University NHS Foundation 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 Embed revised neurological deterioration and escalation standards within ALERT and accredited Immediate Life Support training programmes.
Verbatim wording from the response “Importantly, this policy update is not solely procedural amendments but are actively embedded within the Trust’s education and training infrastructure. The revised standards now inform and support the following programmes:” Source location Response from East Kent Hospitals University NHS Foundation 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 No CT scan was warranted because there were no trauma signs, neurological indicators, or other clinical features requiring imaging after naloxone response.
Verbatim wording from the response “████████, in preparation for this response has confirmed that his stance would remain the same. The evidence and handover from the paramedics on arrival was clear on the history of Mrs Heaver. Whilst the timing of the overdose was unclear, she had no signs of trauma i.e. a head injury which would have necessitated a CT. It was evident that she had taken an overdose and the medication blisters packs were found next to her.” Source location Response from East Kent Hospitals University NHS Foundation 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 KPMT is responsible for providing the full response concerning access to psychiatric input or prescribing after acute hospital discharge.
Verbatim wording from the response “We believe that this was an issue that arose at the inquest itself and KPMT will respond to this in full.” Source location Response from East Kent Hospitals University NHS Foundation Trust
Open published response
7 Nov 2025 Ernest Roy Gray · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 5 Failure to communicate patients’ ongoing needs after discharge View source Failure to provide carers with guidance on recognising and responding to delirium symptoms View source Failure to communicate relevant delirium risks and behavioural history to carers View source Lack of holistic discharge planning View source Failure to involve the patient’s cohabiting carer in discharge planning View source See 2 more concerns
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
Ernest Roy Gray · 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
Ernest Roy Gray was admitted to hospital after a myocardial infarction and developed hyperactive delirium and heart failure, with episodes of agitation and aggression. He was discharged home while still confused and later became unwell, was admitted to hospital, developed pneumonia, and died on 24 November 2023. Concerns included failure to involve his partner in discharge planning, inadequate holistic discharge planning and communication, and insufficient information about the possible fluctuating and aggressive manifestations of his delirium and what to do if symptoms occurred.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate patients’ ongoing needs after discharge
Wider context from the report “(2) Although a number of persons from different disciplines were involved in planning Mr. Gray’s discharge, there was no evidence of a holistic approach being taken of the discharge or in communication of the patient’s ongoing needs following discharge
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide carers with guidance on recognising and responding to delirium symptoms
Wider context from the report “(3) Mr. Gray’s daughter was informed two days before the discharge that he had hyperactive delirium and that it would resolve itself but could take a few weeks. She was not made aware that Mr. Gray had at times been agitated and violent in hospital, nor was she told that although the hyperactive delirium was resolving it could fluctuate because it was likely triggered by a metabolic cause (renal function), heart failure or myocardial infarction. Neither she nor Mr. Gray’s partner were informed as to how symptoms may manifest or what to do if Mr. Gray was symptomatic . Had they known that Mr. Gray may become aggressive or violent to others particularly his carers, an early discharge would not have been encouraged
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant delirium risks and behavioural history to carers
Wider context from the report “(3) Mr. Gray’s daughter was informed two days before the discharge that he had hyperactive delirium and that it would resolve itself but could take a few weeks. She was not made aware that Mr. Gray had at times been agitated and violent in hospital , nor was she told that although the hyperactive delirium was resolving it could fluctuate because it was likely triggered by a metabolic cause (renal function), heart failure or myocardial infarction . Neither she nor Mr. Gray’s partner were informed as to how symptoms may manifest or what to do if Mr. Gray was symptomatic. Had they known that Mr. Gray may become aggressive or violent to others particularly his carers, an early discharge would not have been encouraged
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of holistic discharge planning
Wider context from the report “(2) Although a number of persons from different disciplines were involved in planning Mr. Gray’s discharge, there was no evidence of a holistic approach being taken of the discharge or in communication of the patient’s ongoing needs following discharge
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve the patient’s cohabiting carer in discharge planning
Wider context from the report “(1) Mr. Gray’s next of kin was his daughter but he lived with his 86 year old partner. His daughter was consulted in the discharge process but the hospital did not attempt to contact his partner who was his carer .
” 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 Request and develop IT record changes to distinguish carers from next of kin.
Verbatim wording from the response “1. We have requested IT record changes to correctly identify the carer(s) involved so they can be involved in appropriate discussions and decisions. Our current IT systems do not allow us to differentiate ‘carer’ from ‘next of kin’ (they can be different as was the case with Mr Gray). We recognise that this will be key in clearly identifying the carer for future discharge conversations so we have raised this urgently with the Sunrise team to investigate. The request has been made and is being prioritised.” Source location Response from East Kent Hospitals University NHS Foundation 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 Establish a multi-agency workstream to identify resources and improve ongoing support after discharge for patients with delirium.
Verbatim wording from the response “5. A workstream has been set up with multiple partners; Kent Community Health Trust, East Kent Hospital University Foundation Trust (EKHUFT) Kent and Medway Mental Health Trust, Kent County Council and Carers Support. The purpose of this group is to identify resources, where we can work together to improve the discharge of patients with delirium, to ensure on going patient and carer support. This Workstream is chaired by the Director of Adult Services for Kent Community and is anticipated to start in a few weeks.” Source location Response from East Kent Hospitals University NHS Foundation 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 Share the Delirium leaflet with families and carers at discharge.
Verbatim wording from the response “1. Review of the existing Delirium leaflet will be shared as appropriate on patient discharge. This leaflet has been reviewed and is easily accessible on the Trust intranet. A hard copy will be handed out to families/carers for information.” Source location Response from East Kent Hospitals University NHS Foundation 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 Re-audit progress on carer identification and support in February, March and April.
Verbatim wording from the response “9. Mapping of Progress by re-audit by the Carers Champion will take place in February, March and April this year.” Source location Response from East Kent Hospitals University NHS Foundation 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 Review and make the Delirium leaflet accessible on the Trust intranet.
Verbatim wording from the response “1. Review of the existing Delirium leaflet will be shared as appropriate on patient discharge. This leaflet has been reviewed and is easily accessible on the Trust intranet. A hard copy will be handed out to families/carers for information.” Source location Response from East Kent Hospitals University NHS Foundation 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 Develop discharge contact information linking patients and carers with community support services and urgent response services.
Verbatim wording from the response “3. A wider piece of work is underway to provide all patients with contact numbers in case they require additional community support, on their discharge. This will include the contact number of the carer champion but also signpost patient and carers to services such as Carer Support, the Kent County council (social care) number and an East Kent wide urgent response number. This number will be appropriate for carers of patients with delirium or confusion who are deteriorating unexpectedly.” Source location Response from East Kent Hospitals University NHS Foundation 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 Audit identification of carers and their support needs among patients aged 70 or over.
Verbatim wording from the response “2. We carried out a snapshot audit in January 2026 of a sample of up to 50 patients aged 70 or over to specifically investigate how their carer is currently identified on our IT systems and from then, what support the carer may require to give assurances that the Carer’s Policy and Discharge Policy is being followed. Early findings as is frequently seen; is that families of confused patients are becoming exhausted and unable to cope. They are currently only identified as ‘NOK’, followed by their relationship (son, daughter) and not whether they are the carer. The planned addition of the NOK field will allow for easier audits and monitoring in the future.” Source location Response from East Kent Hospitals University NHS Foundation 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 Provide Carer Champion contact details and an updated discharge leaflet signposting support services.
Verbatim wording from the response “6. The telephone number of the Carer Champion and an updated discharge leaflet will be provided to signpost the patient or carer to support services they may need once at home.” Source location Response from East Kent Hospitals University NHS Foundation 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 Provide the developed care advice leaflet to all patients with a carer after discharge.
Verbatim wording from the response “4. A care advice leaflet has already been developed to support this and is available on the Trust intranet. Going forward this will be provided to all patients with a carer following discharge.” Source location Response from East Kent Hospitals University NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce next-day post-discharge calls to patients or carers to identify support shortfalls.
Verbatim wording from the response “5. We have implemented a post- discharge plan to support the patient and carer. It is proposed the Carer’s champion (or delegate) will call the patient (or carer) on the day following their discharge to ensure everything is as expected and pick up any shortfalls in the provision early.” Source location Response from East Kent Hospitals University NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a live electronic Discharge Planning Form for multidisciplinary discharge decision-making.
Verbatim wording from the response “2. A new innovation to support all patients’ discharge is the Discharge Planning Form, a new ‘live’ form on the Trust’s electronic patient record. All members of the MDT utilise this form and it is a live document enabling joint and rapid decision making where everyone can see others comments in one place.” Source location Response from East Kent Hospitals University NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and operate a Carer Champion post supporting carer identification and involvement in discharge discussions.
Verbatim wording from the response “3. We have allocated an experienced discharge advisor to a new Carer’s Champion post. This individual has been identified, and they commenced their role in early January. They will support the ward multi-disciplinary teams to identify the patient’s carer and ensure that the carer themselves is involved in the discharge discussions from early in the admission.” Source location Response from East Kent Hospitals University NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The patient’s subsequent aggression was not predicted because there was no previous evidence of aggression.
Verbatim wording from the response “While a therapy assessment appointment had been arranged to attend Mr Gray’s home following discharge, this unfortunately did not take place in time to prevent the tragic death of his partner. It is a common occurrence that patients are discharged with ongoing confusion, and it is recognised that this will often be eased, by being in familiar surroundings. There had been no previous evidence of any aggression in Mr Gray, and the tragic events that followed were absolutely not predicted.” Source location Response from East Kent Hospitals University NHS Foundation Trust
Open published response
17 Jun 2025 Upali Meththanananda · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 3 Failure to document discussions and advice from other organisations or third parties View source Failure to use required procedure forms and document procedures View source Failure to document clinical events and observations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Upali Meththanananda · 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
Upali Meththanananda underwent coronary artery bypass surgery and was later admitted with a large left-sided pleural effusion. He died after a chest drain inserted on 20 October 2023 was followed by hypovolaemia, bleeding and cardiorespiratory arrest; concerns were raised about inadequate documentation of observations, procedures and discussions between clinicians.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document discussions and advice from other organisations or third parties
Wider context from the report “(1) I was concerned about the documentation as the inquest process had been hampered by the poor documentation and whilst I accepted that clinicians may have been providing care and not always documenting the care provided during this time the importance of documentation cannot be understated. However it was not just in the emergency setting where the clinical notes were lacking the clinical notes did not record key events and observations taken even in the period prior to his collapse. Clinical observations were not documented, meaning that trends were not available to treating clinicians and they would not have a full picture upon which to base any clinical decisions. Discussions between clinicians at other organisations were also not documented and forms used by the hospital for procedures were not used as required even by experienced clinicians. Whilst I heard some improvements had been made by the witness who presented the Trust's action plan I remained concerned that the failure to document procedures and observations as well as advice given from third parties could lead to clinicians who take over care for a patient not having a full picture and leading to risks to patients in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use required procedure forms and document procedures
Wider context from the report “(1) I was concerned about the documentation as the inquest process had been hampered by the poor documentation and whilst I accepted that clinicians may have been providing care and not always documenting the care provided during this time the importance of documentation cannot be understated. However it was not just in the emergency setting where the clinical notes were lacking the clinical notes did not record key events and observations taken even in the period prior to his collapse. Clinical observations were not documented, meaning that trends were not available to treating clinicians and they would not have a full picture upon which to base any clinical decisions. Discussions between clinicians at other organisations were also not documented and forms used by the hospital for procedures were not used as required even by experienced clinicians . Whilst I heard some improvements had been made by the witness who presented the Trust's action plan I remained concerned that the failure to document procedures and observations as well as advice given from third parties could lead to clinicians who take over care for a patient not having a full picture and leading to risks to patients in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document clinical events and observations
Wider context from the report “(1) I was concerned about the documentation as the inquest process had been hampered by the poor documentation and whilst I accepted that clinicians may have been providing care and not always documenting the care provided during this time the importance of documentation cannot be understated. However it was not just in the emergency setting where the clinical notes were lacking the clinical notes did not record key events and observations taken even in the period prior to his collapse . Clinical observations were not documented , meaning that trends were not available to treating clinicians and they would not have a full picture upon which to base any clinical decisions. Discussions between clinicians at other organisations were also not documented and forms used by the hospital for procedures were not used as required even by experienced clinicians. Whilst I heard some improvements had been made by the witness who presented the Trust's action plan I remained concerned that the failure to document procedures and observations as well as advice given from third parties could lead to clinicians who take over care for a patient not having a full picture and leading to risks to patients in the future.
” 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 Begin a Surgical Teams trial of the Sunrise Mobile application on tablet devices to assess point-of-care documentation.
Verbatim wording from the response “○ A trial will begin in the Surgical Teams at QEQM in August with the use of the 'Sunrise Mobile' (Sunrise™ - EKHUFT Electronic Medical Record (EMR)) application on a tablet device to assess whether this can facilitate more real-time documentation at the point of care to improve the quality of documentation in an acute setting by providing an easier and more portable hardware device over a computer on wheels.” Source location 2025-0308 Response from East Kent Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Plan ongoing documentation audits within Care Groups to monitor quality and improvement progress.
Verbatim wording from the response “As part of our commitment to continually review and improve quality we recently undertook a trust wide audit supported by our Clinical Audit and Improvement Team of documentation across the organisation in all representative care settings. This highlighted a number of areas for improvement of both digital and written documentation which will be presented to our Operational Quality Governance Committee for support and communication across Care Groups. Following this ongoing documentation audits will be planned within Care Groups to monitor quality and progress in improvement.” Source location 2025-0308 Response from East Kent Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Plan digitisation of surgical care plans and review Local Safety Standards for Invasive Procedures to support digital documentation and compliance.
Verbatim wording from the response “○ The digitisation of the surgical care plan documentation is being planned and along with this a review of Local Safety Standards for Invasive Procedures (“LocSSIPs”) to plan for digitisation. This will ensure they are always visible in the medical record and drive compliance with documentation through mandating where appropriate data entry.” Source location 2025-0308 Response from East Kent Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the improved Electronic Discharge Notification for clearer clinical documentation.
Verbatim wording from the response “○ A communication plan will be actioned in August (importantly coinciding with the new intake of Resident Doctors in August as part of their training) to continue to highlight the importance of accurate and timely clinical documentation both in the inpatient and emergency settings but also in the discharge of patients to our clinical colleagues in the community through the Electronic Discharge Notification (EDN). A new EDN went live in April with significant improvements in clarity of documentation. The communications plan specifically addresses the use of 'copy and pasting' within the digital clinical notes.” Source location 2025-0308 Response from East Kent Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install improved electronic medical record trend charting to show observation-parameter trends over time.
Verbatim wording from the response “○ We are waiting for our Electronic Medical Record (EMR) supplier to install an improved trend charting which will allow clearer visibility of trends in specific observation parameters over time (i.e. 24 hours/12 hours). This should be installed by the end of September 2025.” Source location 2025-0308 Response from East Kent Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct Gemba walks in emergency and inpatient settings to identify documentation and point-of-care process improvements.
Verbatim wording from the response “○ Gemba walks were conducted across the emergency and inpatient settings on the 3rd July and 1st August at Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate. A Gemba walk is a walk through of the clinical environment for senior leaders to review how processes are working in real time at the point of care to see for themselves where issues are arising. Actions are then set to follow up on these issues and improve the interface between patient care and note taking.” Source location 2025-0308 Response from East Kent Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake IT and Clinical IT team walks to review hardware provision, accessibility and reliability for real-time documentation.
Verbatim wording from the response “○ Following feedback from the Gemba walks, additional IT Technical Team walks of the emergency and inpatient settings along with the Clinical IT Team will be undertaken in August to review the current IT hardware across settings. We will review provision, accessibility and reliability of hardware to ensure clinical teams have access to the right technology at the point of care to facilitate and encourage real-time documentation and recording of clinical parameters and observations.” Source location 2025-0308 Response from East Kent Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a trust-wide audit of clinical documentation across representative care settings.
Verbatim wording from the response “As part of our commitment to continually review and improve quality we recently undertook a trust wide audit supported by our Clinical Audit and Improvement Team of documentation across the organisation in all representative care settings. This highlighted a number of areas for improvement of both digital and written documentation which will be presented to our Operational Quality Governance Committee for support and communication across Care Groups. Following this ongoing documentation audits will be planned within Care Groups to monitor quality and progress in improvement.” Source location 2025-0308 Response from East Kent Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a communication plan highlighting accurate, timely clinical documentation, discharge documentation and appropriate use of copying and pasting.
Verbatim wording from the response “○ A communication plan will be actioned in August (importantly coinciding with the new intake of Resident Doctors in August as part of their training) to continue to highlight the importance of accurate and timely clinical documentation both in the inpatient and emergency settings but also in the discharge of patients to our clinical colleagues in the community through the Electronic Discharge Notification (EDN). A new EDN went live in April with significant improvements in clarity of documentation. The communications plan specifically addresses the use of 'copy and pasting' within the digital clinical notes.” Source location 2025-0308 Response from East Kent Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing documentation improvement plans and re-audit to assess whether improvements are being made.
Verbatim wording from the response “We will continue to review these plans and re-audit to ensure that improvements are being made.” Source location 2025-0308 Response from East Kent Hospitals NHS Trust
Open published response
7 Jun 2025 Mrs Ann Caldicott · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 4 Failure to conduct internal investigations for learning View source Failure to consider support for nutritional status View source Failure to investigate malnutrition and declining frailty View source Poor nutritional state compromising suitability for lifesaving treatment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Ann Caldicott · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Ann Caldicott had a long-standing history of weight loss, anaemia, declining renal function and frailty, and died in hospital on 21 February 2024 after a urinary catheter insertion caused a bladder perforation. The report identifies concerns that her malnutrition and declining frailty were not adequately investigated or treated, leaving her too physiologically frail for potentially lifesaving treatment. It also raises concerns that relevant internal investigations and reviews did not take place.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct internal investigations for learning
Wider context from the report “2. Ann’s marked Anemia and poor nutritional state meant that she was not suitable for potentially lifesaving treatment when it became necessary.
3. No internal investigations were conducted by Ann’s GP or by the East Kent Hospitals NHS Foundation Trust to establish if lessons could be learned as a result of the circumstances of Ann’s Death.
4. The Court was informed that there had been an SJR (of which I had not previously been notified) following Ann’s death. The Dr providing evidence was to raise a Datix in relation to Ann’s previous attendances and failed discharges. At the resumed inquest the Court were informed these investigations had not taken place and were not to take place .
5. No consideration was given prior to Ann’s final admission and some 18 months after the onset of symptoms of vomiting and chronic weightless, of support for Ann’s nutritional status.
6. If Ann had been in a better nutritional state on her final admission to the Kent and Canterbury, then she would have been well enough to undergo lifesaving treatment following the bladder perforation.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider support for nutritional status
Wider context from the report “2. Ann’s marked Anemia and poor nutritional state meant that she was not suitable for potentially lifesaving treatment when it became necessary.
3. No internal investigations were conducted by Ann’s GP or by the East Kent Hospitals NHS Foundation Trust to establish if lessons could be learned as a result of the circumstances of Ann’s Death.
4. The Court was informed that there had been an SJR (of which I had not previously been notified) following Ann’s death. The Dr providing evidence was to raise a Datix in relation to Ann’s previous attendances and failed discharges. At the resumed inquest the Court were informed these investigations had not taken place and were not to take place.
5. No consideration was given prior to Ann’s final admission and some 18 months after the onset of symptoms of vomiting and chronic weightless, of support for Ann’s nutritional status.
6. If Ann had been in a better nutritional state on her final admission to the Kent and Canterbury, then she would have been well enough to undergo lifesaving treatment following the bladder perforation.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate malnutrition and declining frailty
Wider context from the report “1. Ann’s malnutrition and declining frailty were not investigated despite continued requests by Ann and her family to primary and secondary care settings .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor nutritional state compromising suitability for lifesaving treatment
Wider context from the report “2. Ann’s marked Anemia and poor nutritional state meant that she was not suitable for potentially lifesaving treatment when it became necessary.
3. No internal investigations were conducted by Ann’s GP or by the East Kent Hospitals NHS Foundation Trust to establish if lessons could be learned as a result of the circumstances of Ann’s Death.
4. The Court was informed that there had been an SJR (of which I had not previously been notified) following Ann’s death. The Dr providing evidence was to raise a Datix in relation to Ann’s previous attendances and failed discharges. At the resumed inquest the Court were informed these investigations had not taken place and were not to take place.
5. No consideration was given prior to Ann’s final admission and some 18 months after the onset of symptoms of vomiting and chronic weightless, of support for Ann’s nutritional status.
6. If Ann had been in a better nutritional state on her final admission to the Kent and Canterbury, then she would have been well enough to undergo lifesaving treatment following the bladder perforation.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver essential nutrition training to all staff groups.
Verbatim wording from the response “Prior to the issuing of the PFD, and as part of our expected processes, a Nutrition Trust Wide Improvement Plan (“TWIP”) had been developed for 2025/26. This followed an internal review of quality indicators across the previous year which had demonstrated inconsistent standards of nutritional care being provided, including contributing factors of gaps in staff knowledge (for example around naso-gastric feeding), and nutrition and hydration not consistently being discussed as part of the Multi-Disciplinary Team (MDT) board rounds, which can hinder timely recognition and management of these patients’ nutritional needs.” Source location Response from East Kent Hospitals University
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 Provide additional support to the Medical Examiner team to identify cases for further investigation.
Verbatim wording from the response “We have highlighted this case to the Lead Medical Examiner as the first point at which it was felt a Structured Judgement Review could have taken place. If this had happened then it would have triggered many other actions and the Trust could have learned from this case earlier than it has now. Individual feedback has been provided and additional support will be provided to the Medical Examiner team to allow them to better identify cases for further investigation.” Source location Response from East Kent Hospitals University
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing learning from incidents, complaints, claims and inquests to improve governance and patient safety.
Verbatim wording from the response “Regrettably, the clinician who gave evidence at the Inquest did not raise a Datix and therefore, once again, the opportunity to investigate and learn was lost. We apologise that this wasn’t completed in a timely manner but the clinicians have been received feedback and they have reflected on the importance of raising incidents for learning and improvement. The Trust realises this is not reassuring but we believe this to be an isolated incident. However, as part of our commitment to improving governance and patient safety, the Trust will continue to review learning from incidents, complaints, claims and inquests.” Source location Response from East Kent Hospitals University
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 daily ward processes to identify nutrition-risk patients early and implement appropriate care plans.
Verbatim wording from the response “Prior to the issuing of the PFD, and as part of our expected processes, a Nutrition Trust Wide Improvement Plan (“TWIP”) had been developed for 2025/26. This followed an internal review of quality indicators across the previous year which had demonstrated inconsistent standards of nutritional care being provided, including contributing factors of gaps in staff knowledge (for example around naso-gastric feeding), and nutrition and hydration not consistently being discussed as part of the Multi-Disciplinary Team (MDT) board rounds, which can hinder timely recognition and management of these patients’ nutritional needs.” Source location Response from East Kent Hospitals University
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 Undertake a full multidisciplinary case-note review of care and treatment preceding the final admission to identify earlier holistic recognition of decline.
Verbatim wording from the response “A multi professional review of the 12 months care and treatment preceding her admission late 2023 will take place. This is described further later in this letter.” Source location Response from East Kent Hospitals University
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 Strengthen multidisciplinary-team processes for clinical leadership of nutritional care.
Verbatim wording from the response “In light of the coroner’s findings, the TWIP has been re-reviewed and the MDT element further strengthened, to ensure clear clinical leadership, to drive lasting improvements.” Source location Response from East Kent Hospitals University
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 It is impossible to determine whether earlier nutritional optimisation would have enabled lifesaving treatment; other conditions likely drove the poor nutritional state.
Verbatim wording from the response “The Trust feels this is an opinion better suited for an expert to determine and not one that requires action per se. However, the William Harvey Clinical lead for Nutrition Dr Helen Mackie, consultant gastroenterologist has stated, that it is difficult to say with any certainty what the probability would have been.” Source location Response from East Kent Hospitals University
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 Manor Clinic, as Mrs Caldicott’s primary care provider, can respond regarding consideration of support for her nutritional status.
Verbatim wording from the response “5. No consideration was given prior to Mrs Caldicott’s final admission and some 18 months after the onset of symptoms of vomiting and chronic weightless, of support for Mrs Caldicott’s nutritional status.” Source location Response from East Kent Hospitals University
Open published response
Concerns raised 6 Lack of clinical staff knowledge of the Acute Abdominal Pain Pathway View source Lack of a clearly documented and recorded process for patient self-discharge View source Failure to maintain a signed record of patient self-discharge View source Failure of the hospital SI process to include information from family and other interested persons View source Failure to record vomiting before hospital discharge View source Failure of the Acute Abdominal Pain Pathway documentation to provide sufficient clarity View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 12
Action
Use the national Patient Safety Incident Investigation report template and include patient and family involvement in learning response reports.
Stated completedThe respondent said that this action was complete when they made their response on 30 September 2024. View source
Action
Add the Acute Abdominal Pain Pathway to the My ED App for clinician access.
Stated completedThe respondent said that this action was complete when they made their response on 30 September 2024. View source
Action
Adopt NHS guidance on engaging and involving patients, families and staff after patient safety incidents.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 September 2024. View source
Action
Establish a Peer Review Panel to review learning response reports.
Stated plannedThe respondent said that this action was planned when they made their response on 30 September 2024. View source
Action
Update the Incident Management Policy to strengthen patient and family involvement, subject to ratification.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 September 2024. View source
Action
Require completion of the Acute Abdominal Pain Pathway for Emergency Department admissions involving abdominal pain.
Stated completedThe respondent said that this action was complete when they made their response on 30 September 2024. View source
Action
Require post-discharge welfare telephone calls for ward patients who self-discharge.
Stated completedThe respondent said that this action was complete when they made their response on 30 September 2024. View source
Action
Update and disseminate policies clarifying staff duties for missing patients and patients attempting self-discharge, including patient risk assessment.
Stated completedThe respondent said that this action was complete when they made their response on 30 September 2024. View source
Action
Implement a Learning Response Review and Improvement Tool for peer review of reports.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 September 2024. View source
Action
Continue joint Emergency Medicine and Surgical teaching sessions reinforcing the Acute Abdominal Pain Pathway.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 September 2024. View source
Action
Issue updated discharge guidance requiring capacity, safeguarding, consultation, medication, notification, documentation and self-discharge form checks.
Stated completedThe respondent said that this action was complete when they made their response on 30 September 2024. View source
Action
Transition incident management to the Patient Safety Incident Response Framework, including patient and family involvement.
Stated completedThe respondent said that this action was complete when they made their response on 30 September 2024. View source See 9 more actions
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AI-generated summary
Megan Ceris Williams · 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
Megan Ceris Williams developed abdominal pain and repeated vomiting between 1 and 5 May 2022, attended hospital twice, and died at home on 5 May 2022 after becoming breathless and losing consciousness. The inquest identified an undiagnosed small bowel obstruction apparently caused by adhesions from previous abdominal surgery. Concerns included possible missed opportunities for investigation, limited staff knowledge and clarity of the Acute Abdominal Pain Pathway, the lack of a signed self-discharge record, and the hospital investigation process not including information from family members.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical staff knowledge of the Acute Abdominal Pain Pathway
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP) .
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clearly documented and recorded process for patient self-discharge
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a signed record of patient self-discharge
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the hospital SI process to include information from family and other interested persons
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family .
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise .
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record vomiting before hospital discharge
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Acute Abdominal Pain Pathway documentation to provide sufficient clarity
Wider context from the report “Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery.
It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction.
The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022.
The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene.
The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged.
The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning.
The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family.
(a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP).
(b) Given what was said about how clear the AAPP was , that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians.
(c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise.
(d) There was not a clearly documented and recorded process for patients who self-discharge from hospital.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the national Patient Safety Incident Investigation report template and include patient and family involvement in learning response reports.
Verbatim wording from the response “The Patient Safety Incident Response Framework and our Trust plan requires the use of a Patient Safety Incident Investigation (PSII) methodology for certain incident types. The Trust has adopted the national template for PSII reports (Document 6). This includes recording of the patient and family involvement in the investigation process. The other learning response reports that the Trust will be using e.g. After Action Review, Swarm, also prompt the inclusion of the patient and family perspective.” Source location Response from East Kent Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add the Acute Abdominal Pain Pathway to the My ED App for clinician access.
Verbatim wording from the response “In addition, the Trust’s Updated Action Plan implemented a procedure whereby a copy of the AAPP needs to be fully completed when a patient is admitted to the Emergency Department with complaints of abdominal pain. This process was implemented on 07 September 2022. Furthermore, as of 13 September 2022, the AAPP has now been added to the My ED App, this is to ensure it is readily and easily accessible to clinical staff assessing patients with complaints of abdominal pain.” Source location Response from East Kent Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt NHS guidance on engaging and involving patients, families and staff after patient safety incidents.
Verbatim wording from the response “In addition to the Policy and Plan, the Trust is adopting the NHS Engaging and involving patients, families and staff following a patient safety incident. The Trust’s Incident Management Policy has been updated (pending ratification) to ensure that patient and family involvement is strengthened. Similarly, the Trust’s Duty of Candour Policy (Document 5) will be reviewed and updated. For” Source location Response from East Kent Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a Peer Review Panel to review learning response reports.
Verbatim wording from the response “The Trust is implementing the Learning response review and improvement tool to enable peer review of reports. This includes the descriptor, “People affected by incidents are meaningfully engaged and involved”. This tool will be used by learning response leads and the Peer Review Panel described within the Trust Policy (section 12).” Source location Response from East Kent Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Incident Management Policy to strengthen patient and family involvement, subject to ratification.
Verbatim wording from the response “In addition to the Policy and Plan, the Trust is adopting the NHS Engaging and involving patients, families and staff following a patient safety incident. The Trust’s Incident Management Policy has been updated (pending ratification) to ensure that patient and family involvement is strengthened. Similarly, the Trust’s Duty of Candour Policy (Document 5) will be reviewed and updated. For” Source location Response from East Kent Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require completion of the Acute Abdominal Pain Pathway for Emergency Department admissions involving abdominal pain.
Verbatim wording from the response “In addition, the Trust’s Updated Action Plan implemented a procedure whereby a copy of the AAPP needs to be fully completed when a patient is admitted to the Emergency Department with complaints of abdominal pain. This process was implemented on 07 September 2022. Furthermore, as of 13 September 2022, the AAPP has now been added to the My ED App, this is to ensure it is readily and easily accessible to clinical staff assessing patients with complaints of abdominal pain.” Source location Response from East Kent Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require post-discharge welfare telephone calls for ward patients who self-discharge.
Verbatim wording from the response “Of key importance is that patients are asked to review the Self Discharge Form which must then be filed within the patient’s case notes. The Self Discharge Form sets out the risks of discharging against medical advice and asks a patient to consider these risks before signing the form. This is to ensure that patients have weighed the risks of self-discharge and ensures that there is a recorded process. The Policy also mandates that following discharge, if on a ward, then a welfare check telephone call be made to ensure the patient has arrived home safely.” Source location Response from East Kent Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and disseminate policies clarifying staff duties for missing patients and patients attempting self-discharge, including patient risk assessment.
Verbatim wording from the response “To ensure a repeat of similar incidents does not re-occur, the Trust has also updated its policy relating to patients who self-discharge from hospital. Enclosed with this letter is the Trust’s updated Missing Persons Policy (Document 7) and the Discharge Criteria policy (Document 8). This has been through 3 separate reviews and updates since May 2022 and ensures that the duties of staff members relating to missing patients and patients who are attempting to self-discharge are clearly established. It also now includes an updated Patient Risk Assessment so that staff members can” Source location Response from East Kent Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a Learning Response Review and Improvement Tool for peer review of reports.
Verbatim wording from the response “The Trust is implementing the Learning response review and improvement tool to enable peer review of reports. This includes the descriptor, “People affected by incidents are meaningfully engaged and involved”. This tool will be used by learning response leads and the Peer Review Panel described within the Trust Policy (section 12).” Source location Response from East Kent Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue joint Emergency Medicine and Surgical teaching sessions reinforcing the Acute Abdominal Pain Pathway.
Verbatim wording from the response “The reinforcement of the AAPP is a continuing process and has been happening throughout the last two years within the Trust. The Trust have a monthly joined Emergency Medicine and Surgical teaching session. This is a platform for these Departments to present and discuss cases they face in order to improve patient safety continuously. It is important to note that cases surrounding acute abdomen are frequent and therefore often require discussion of the AAPP. The AAPP is a feature of these discussions each time a relevant case is discussed.” Source location Response from East Kent Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue updated discharge guidance requiring capacity, safeguarding, consultation, medication, notification, documentation and self-discharge form checks.
Verbatim wording from the response “In addition, the Trust has updated the Hospital Discharge and Criteria to Reside Policy. The Policy was updated and issued to all staff at the Trust on 16 February 2023. The updated policy directs staff to always consider the following when a patient indicates that they want to self-discharge:” Source location Response from East Kent Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transition incident management to the Patient Safety Incident Response Framework, including patient and family involvement.
Verbatim wording from the response “Since the conclusion of the inquest, the Trust has changed the SI process to the new Patient Safety Incident Response Framework. The Trust Patient Safety Incident Response Policy (Document 2) and Plan (Document 3) have been agreed and are attached for information.” Source location Response from East Kent Hospitals
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The current training regime is considered sufficient to ensure staff understand the emergency management process for adult abdominal pain.
Verbatim wording from the response “The reinforcement of the AAPP is a continuing process and has been happening throughout the last two years within the Trust. The Trust have a monthly joined Emergency Medicine and Surgical teaching session. This is a platform for these Departments to present and discuss cases they face in order to improve patient safety continuously. It is important to note that cases surrounding acute abdomen are frequent and therefore often require discussion of the AAPP. The AAPP is a feature of these discussions each time a relevant case is discussed.” Source location Response from East Kent Hospitals
Open published response
8 Dec 2023 Jasbir Pahal · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 3 Reliance on ad hoc voluntary interventional neuroradiologist availability for out-of-hours thrombectomy View source Failure of the nearest hyper-acute stroke hospital to offer a thrombectomy service View source Insufficient commissioned out-of-hours thrombectomy provision for stroke patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jasbir Pahal · 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
Jasbir Pahal suffered an acute left middle cerebral artery stroke on 13 November 2022 and was transferred between hospitals while arrangements for thrombectomy were being considered. Imaging later showed extensive infarction, active treatment was withdrawn on 27 November, and she died on 30 November 2022. The principal concern was that thrombectomy access for patients at Calderdale Royal Hospital was available only during limited weekday hours, leaving patients without reliable access to potentially life-saving treatment outside those hours and subjecting access to local arrangements.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on ad hoc voluntary interventional neuroradiologist availability for out-of-hours thrombectomy
Wider context from the report “(6) That this level of service is inadequate is illustrated by the historical practice of thrombectomies being performed at LGI outside of the stated hours on an occasional ad hoc basis, dependent (among other factors) upon the availability and willingness of an interventional neuroradiologist to attend on a voluntary basis when not on call , to perform a potentially life-saving procedure. Among other reasons, it being considered inappropriate that clinicians should be exposed to the moral dilemma of agreeing or declining to perform such a life-saving procedure outside of their working or on-call hours, LTHT has as from June 2023 stopped accepting such ad hoc referrals .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the nearest hyper-acute stroke hospital to offer a thrombectomy service
Wider context from the report “(1) Calderdale Royal Hospital (CRH), the hospital with a hyper-acute stroke unit closest to Jasbir’s home address, does not offer a thrombectomy service, whether in or out of hours .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient commissioned out-of-hours thrombectomy provision for stroke patients
Wider context from the report “(3) In common with similar arrangements applying to other district general hospital NHS Trusts in West Yorkshire, NHS England has commissioned the provision of a thrombectomy service to Calderdale and Huddersfield NHS Foundation Trust (CHFT) stroke patients by Leeds Teaching Hospitals NHS Trust (LTHT), whereby stroke patients admitted to Calderdale Royal Hospital and potentially requiring thrombectomy can be transferred for this purpose to Leeds General Infirmary (LGI).
(4) No similar service has been commissioned for CHFT stroke patients from any other Trust.
(5) The existing arrangement between CHFT and LTHT (and between other Trusts within the Regional Integrated Stroke Delivery Network and LTHT) operates only between 0800 and 1500 hrs on weekdays (Monday to Friday), that is, for 35 out of 168 hours in a week (or 20.8%). Anyone who needs heart hyper-acute stroke unit is at a district general hospital in West Yorkshire and who suffers a stroke outside of those hours during the week, or between 1500 hrs on a Friday and 0800 hrs the following Monday, does not have access to a thrombectomy service .
” Open source report
22 Oct 2022 KEITH RUPERT DIMOND · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 5 Failure to follow Consultant Haematologist anticoagulation advice View source Failure to communicate the iliac artery aneurysm diagnosis to treating clinicians View source Failure to share iliac artery aneurysm information to trigger Consultant Vascular Surgeon advice View source Failure to record reasons for not following Consultant Haematologist anticoagulation advice View source Failure to provide written and family-shared bleeding-risk advice for direct oral anticoagulant medication View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
KEITH RUPERT DIMOND · 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
Keith Dimond died on 24 November 2021 at Queen Elizabeth Queen Mother Hospital following a catastrophic bleed from a ruptured iliac artery aneurysm, with anticoagulation contributing to the excessive bleeding. Concerns included communication failures about the known iliac artery aneurysm, lack of information about bleeding risks when anticoagulation was prescribed, delayed escalation when he deteriorated, and haematology advice on anticoagulation not being followed on two occasions.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow Consultant Haematologist anticoagulation advice
Wider context from the report “(3) Anti-coagulation on readmission was considered complex and the advice of a Consultant Haematologist was sought but not followed on two occasions :
(a) Beriplex and Vitamin K was administered. There was no rationale noted as to why advice to withhold Beriplex was not followed .
(b) There was no record as to why advice to give prophylactic clexane was not administered.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the iliac artery aneurysm diagnosis to treating clinicians
Wider context from the report “(1) Treating Clinicians stated they were not aware of the diagnosis of Iliac Artery Aneurysm previously made at the Trust in August 2019 even though this was set out in the medical records and made at the same time as the diagnosis of Aortic Abdominal Aneurysm that was known. A abdominal surgery and anticoagulation were undertaken without consideration of this information.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share iliac artery aneurysm information to trigger Consultant Vascular Surgeon advice
Wider context from the report “(4) The Consultant Haematologist confirmed that if information of the existence of an Iliac Artery Aneurysm had been shared, they would have sought the advice of a Consultant Vascular Surgeon.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record reasons for not following Consultant Haematologist anticoagulation advice
Wider context from the report “(3) Anti-coagulation on readmission was considered complex and the advice of a Consultant Haematologist was sought but not followed on two occasions:
(a) Beriplex and Vitamin K was administered. There was no rationale noted as to why advice to withhold Beriplex was not followed.
(b) There was no record as to why advice to give prophylactic clexane was not administered.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide written and family-shared bleeding-risk advice for direct oral anticoagulant medication
Wider context from the report “(2) The patient was discharged on 19 October 2022 with a new diagnosis of Atrial Fibrillation and prescription of Direct Oral Anticoagulant Apixaban was prescribed. The patient was not given any written advice on the risks as to bleeding on this medication and the risks were not shared with family on discharge. This led to advice being sought from 111 and a long delay before 999 was called when the patient deteriorated on 22 October 2022.
” 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 Communicate to clinical teams the requirement to document decision-makers and rationales when withholding haematology-advised anticoagulant treatment.
Verbatim wording from the response “It is good practice for all clinical teams to seek advice from the haematologist regarding anti-coagulants if considered complex. Since this incident, we have communicated the importance of documenting who made the decision and the rationale behind withholding treatment that has been advised by the haematologist, for example in response to a rapidly changing clinical picture or additional information coming to light, to all clinical teams. This has been through via training and written communications from the clinical director. This element will also be included within the team learning review at the morbidity and mortality meetings for shared learning.” Source location Response from East Kent Hospitals University
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue improving Sunrise to support record-keeping quality and patient safety.
Verbatim wording from the response “We continue to strive to improve the Sunrise system to support the quality of our record keeping and patient safety and are revisiting training to ensure all clinicians know how to access all parts of the clinical record.” Source location Response from East Kent Hospitals University
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 Ensure surgical clinicians understand their medical-record access responsibilities and include this requirement in new-staff induction.
Verbatim wording from the response “In addition, our surgical site leads are ensuring all the clinicians in the department including seniors, understand their responsibility regarding accessing of medical records in line with GMC good medical practice and this will also be part of our induction for new staff. This case will be discussed at departmental morbidity and mortality meetings Trust wide for additional learning and the individual clinicians involved to include their personal reflection and learning within their annual appraisal.” Source location Response from East Kent Hospitals University
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 Revisit clinician training so staff can access all parts of the clinical record.
Verbatim wording from the response “We continue to strive to improve the Sunrise system to support the quality of our record keeping and patient safety and are revisiting training to ensure all clinicians know how to access all parts of the clinical record.” Source location Response from East Kent Hospitals University
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and expand Sunrise digital clinical documentation, results access and patient-observation recording across the organisation.
Verbatim wording from the response “The Trust has become more digitally mature as an organisation; there have been several developments which have significantly improved the clarity and accessibility of our medical records. In October 2020, we launched Sunrise which provides ordering and viewing of test results. This was followed by the introduction of moving the documentation of the A&E clinical notes onto this system. Following on from this in June 2021 Sunrise was launched onto the wards for all clinical documentation and now includes patient clinical observations (blood pressure, heart rate etc). These significant improvements enable the clinical teams to access digitally the clinical notes and important results in one place which are accessible from anywhere within the organisation.” Source location Response from East Kent Hospitals University
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 Communicate the requirement for accurate information in clinician referrals through clinical directors and regular team training.
Verbatim wording from the response “We accept that the importance of any referral made by a clinician should contain accurate information so that it is understood and acted upon by the responsible clinician. This has been communicated with the clinical directors who have disseminated this information to their clinical teams. In addition to this, it is also being communicated through the training sessions which are delivered to the clinical teams regularly.” Source location Response from East Kent Hospitals University
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 Create and implement a generic anticoagulant discharge leaflet covering bleeding risks, warning signs and when to seek medical attention.
Verbatim wording from the response “I can confirm that the Trust is in the process of creating and implementing a generic anticoagulant patient leaflet, which will be provided to patients upon discharge from hospital. The leaflet will cover information around risks of bleeding, signs and symptoms to look for in terms of bleeding and when to seek medical attention. The leaflet is due to be finalised by the end of March 2023.” Source location Response from East Kent Hospitals University
Open published response
28 Feb 2022 Neil HICKMAN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Failure to measure ferritin levels in patients receiving frequent platelet transfusions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Neil HICKMAN · 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
Neil Hickman was treated for myelodysplastic syndrome and referred for a stem cell transplant, but died before the transplant could take place from disseminated angio-invasive mycotic infection in the context of immunosuppression and myelodysplasia. The concern was that frequent platelet transfusions at Kent and Canterbury Hospital were not accompanied by ferritin measurements, meaning iron overload might go undetected, although this did not affect the outcome in his case.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to measure ferritin levels in patients receiving frequent platelet transfusions
Wider context from the report “Mr Hickman was given frequent platelet transfusions at K&C, but his ferritin levels were not measured . When he was referred to UCLH, his ferritin level was found to be hugely raised. He was then treated with chelation therapy and ultimately his ferritin returned to a safe level, so this did not impact upon the outcome. However, it might for another patient.
I think the reason that K&C does not measure the ferritin levels in such a situation is because K&C does not have funding for chelation therapy to treat iron overload. However, if iron overload is detected, then a referral centre such as UCLH can be called for advice, and the patient and their family can be informed so that they have the option of seeking private treatment.
” Open source report
22 Feb 2022 Mr Osland · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 6 Failure to ensure reconnection of the central monitor to the room monitor after silencing an ‘OFF COMS’ alert View source Failure to ensure timely rectification of disconnections between room and central monitors View source Failure to include room alarm audibility in handover equipment checks View source Failure to respond to persistent ‘OFF COMS’ monitor notifications View source Lack of defined nursing response steps for ‘OFF COMS’ alerts and notifications View source Failure to document reductions in room monitor alert volume View source See 3 more concerns
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AI-generated summary
Mr Osland · 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
Mr Osland was admitted to hospital after an ischaemic stroke and later suffered hypoxia, cardiorespiratory arrest and catastrophic ischaemic brain injury. He did not regain consciousness and died after the withdrawal of clinical support. The principal concerns were reduced room-monitor alarm volume, disconnection between the room and central monitors, inadequate responses to the persistent “OFF COMS” notification, and unclear procedures for nursing staff.
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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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure reconnection of the central monitor to the room monitor after silencing an ‘OFF COMS’ alert
Wider context from the report “3) After silencing the ‘OFF COMS’ alert on the central monitor, no steps were taken to ensure it was reconnected to the room monitor .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely rectification of disconnections between room and central monitors
Wider context from the report “5) Specifically in respect of points 3 & 4, it is unclear as to when the ‘OFF COMS’ disconnection between the room and central monitor would have been rectified had it not come to light after Mr Osland’s arrest.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include room alarm audibility in handover equipment checks
Wider context from the report “1) Nursing staff are unaware that the room monitor volume could be reduced to the point where it was not audible outside the room – as a result, the volume of the room alarm was not part of hand over equipment checks .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to persistent ‘OFF COMS’ monitor notifications
Wider context from the report “4) No steps had been taken to respond to the ‘OFF COMS’ notification on the central monitor screen which had persisted for the 5 days prior to the 26th April 2021
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of defined nursing response steps for ‘OFF COMS’ alerts and notifications
Wider context from the report “6) It was unclear what steps nurses were supposed to take when confronted with an ‘OFF COMS’ alert or screen notification .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document reductions in room monitor alert volume
Wider context from the report “2) The circumstances in which the room monitor alerts were reduced were not documented , and accordingly subsequent staff would not be aware that they had been so reduced
” 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 Operate a strengthened EME fault-reporting process with call logging, receipt confirmation and EQUIP tracking of outstanding or recurring issues.
Verbatim wording from the response “Since this incident, EME have carried out an inspection of the ICU Department’s electrical supply system. As a result, they identified faults with the cabling which could have affected the connection of monitors to the central monitor. The entirety of the cabling in ICU at Kent & Canterbury Hospital has been replaced to improve connectivity and since this has been carried out there have been no issues with connectivity. If the ‘OFF COMS’ alert appears, the process is to inform the Nurse in Charge and report this to EME as soon as the staff are made aware of the issue. The process of reporting issues to EME is now more robust with logging and receipt of calls and the Trust now uses a dedicated IT system (EQUIP) which allows for a review of any issues that are outstanding or recurring themes that need to be acted upon.” Source location 2022-0060-Response-from-Kent-Canterbury-Hospital_Published
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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 Review alarm levels during configuration of current ICU monitors and agree settings through the configuration working group.
Verbatim wording from the response “However, if EME have been requested to change the volumes, this will be documented along with an individualised risk assessment in the patient record. In future, a review of alarm levels will take place as part of our configuration of current ICU monitors but I can assure you that volumes will be set at a level which will be agreed by the configuration working group which comprises of critical care, medical devices, EME and GE Healthcare (manufacturer of the monitors).” Source location 2022-0060-Response-from-Kent-Canterbury-Hospital_Published
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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 Document EME-requested alarm-volume changes and complete an individualised risk assessment in the patient record.
Verbatim wording from the response “However, if EME have been requested to change the volumes, this will be documented along with an individualised risk assessment in the patient record. In future, a review of alarm levels will take place as part of our configuration of current ICU monitors but I can assure you that volumes will be set at a level which will be agreed by the configuration working group which comprises of critical care, medical devices, EME and GE Healthcare (manufacturer of the monitors).” Source location 2022-0060-Response-from-Kent-Canterbury-Hospital_Published
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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 Conduct and record twice-daily audits confirming that every ICU monitor is connected to the central monitoring system.
Verbatim wording from the response “Additionally, we have implemented twice daily audit checks on the central monitoring system to ensure that it is connected with every monitor in ICU - these checks are recorded in the unit diary.” Source location 2022-0060-Response-from-Kent-Canterbury-Hospital_Published
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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 Replace all ICU cabling at Kent & Canterbury Hospital to improve connectivity between room and central monitors.
Verbatim wording from the response “Since this incident, EME have carried out an inspection of the ICU Department’s electrical supply system. As a result, they identified faults with the cabling which could have affected the connection of monitors to the central monitor. The entirety of the cabling in ICU at Kent & Canterbury Hospital has been replaced to improve connectivity and since this has been carried out there have been no issues with connectivity. If the ‘OFF COMS’ alert appears, the process is to inform the Nurse in Charge and report this to EME as soon as the staff are made aware of the issue. The process of reporting issues to EME is now more robust with logging and receipt of calls and the Trust now uses a dedicated IT system (EQUIP) which allows for a review of any issues that are outstanding or recurring themes that need to be acted upon.” Source location 2022-0060-Response-from-Kent-Canterbury-Hospital_Published
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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 Default ICU monitor alarm volumes to levels 8–10 and restrict volume changes to EME staff on request.
Verbatim wording from the response “The volumes on the monitors have now been defaulted to 8-10 (which is the highest volume on the machine) and cannot be reduced by the ICU (Intensive Care Unit) staff. ICU staff are now not able to reduce and set the alarms on these machines themselves and this can only be carried out by the Trust’s Electrical and Mechanical Engineering Department (EME) on request. As a result of this change, volumes of the alarms will not routinely be required to be discussed at handover.” Source location 2022-0060-Response-from-Kent-Canterbury-Hospital_Published
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11 Aug 2021 Hadley John Savory · Prevention of Future Deaths report North East Kent
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Concerns raised 2 Lack of evidence of multi-agency procedures for safe discharge of patients with concurrent mental health, substance misuse, social care and physical health needs View source Lack of evidence of multi-agency planning meetings before discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Hadley John Savory · 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
Hadley John Savory was discharged from hospital on 25 September 2019, and his presentation later declined in the community. He was found deceased at home on 13 December 2019 after toxicological evidence indicated that he had taken a lethal dose of methadone; concerns included the absence of a multi-agency planning meeting before discharge and unclear multi-agency procedures for supporting patients with concurrent health, substance misuse and social care needs.
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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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of evidence of multi-agency procedures for safe discharge of patients with concurrent mental health, substance misuse, social care and physical health needs
Wider context from the report “(1) There was no evidence of a multi agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs ;
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of evidence of multi-agency planning meetings before discharge
Wider context from the report “(1) There was no evidence of a multi agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs;
” Open source report
Concerns raised 2 Failure to accurately complete and reconcile fluid balance charts View source Lack of a pathway for investigating dysphagia caused by an oesophageal stricture View source
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Each statement is shown once, even when linked to more than one concern.
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Lynda Pedersen · 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
Lynda Pedersen died on 7 September 2018 in hospital from aspiration pneumonitis, pneumonia and fluid overload due to a stricture caused by an adenocarcinoma of the oesophagogastric junction. The adenocarcinoma was not identified during her admission or during earlier medical care following an admission for dysphagia. Concerns included the lack of a pathway for investigating dysphagia caused by a stricture, which contributed to the need to investigate malignancy being lost, and deficiencies in fluid balance charting and recording of fluid output before her death.
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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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately complete and reconcile fluid balance charts
Wider context from the report “(2) Fluid balance charts were not correctly completed in the period leading to Lynda Pedersen’s death. The evidence from the fluid balance charts showed that she was carrying fluids forward until the time of her death; there being an imbalance to the tune of some 3 1/2 litres. That there was a significant fluid overload was also evident from the pathology. That she had a fluid overload was only identified by the hospital at a time that she was temporally close to death. It was accepted at the inquest that the charts were deficient in their completion, that nursing staff had not recorded output properly or reconciled the balance as required .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a pathway for investigating dysphagia caused by an oesophageal stricture
Wider context from the report “(1) Lynda Pedersen was admitted to William Harvey Hospital on 6th September 2017 with dysphagia. A gastroscopy conducted two days later identified a stricture within the oesophagus with the appearance of the mucosa suggestive of a submucosal infiltration. A CT scan did not identify a malignancy but indicated that the area of concern could not be evaluated as it had not been distended by the orally ingested contrast. Lynda Pedersen had a number of further gastroscopies to attempt to dilate her oesophagus between 2017 and 2018 some of which reported a benign appearance but the cause of the stricture was never investigated despite the risk of variceal bleeding having been significantly reduced by a TIPS procedure having been conducted on 11th October 2017. It was accepted that a biopsy should have been undertaken but the need for investigation as to whether there was a malignancy was lost in that the clinicians’ focus was on attempting to improve her nutritional status and quality of life. The reason for the loss of the need for an investigation was twofold: there was no pathway in place for dysphagia presentation caused by a stricture and the fact of multiple presentations. It was agreed by the treating clinicians and an independent expert that had there been a pathway in place, the investigation for cancer was less likely to have been lost . The clinicians who gave evidence at the Inquest were of the view that this was a matter most appropriately addressed by NHS England and NHS Improvements.
” 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 multidisciplinary education on the importance of accurate fluid-balance monitoring.
Verbatim wording from the response “The Trust is focused on improving how we monitor fluid balance through the completion of fluid balance charts in all areas of the Trust. We have addressed this through supporting our clinical leadership teams in understanding their roles and responsibilities to ensure best practice in their wards by medical and nursing teams. We have undertaken multi-disciplinary education programmes on the importance of accurate fluid balance monitoring and regularly audit of the completion of fluid balance charts.
Our Deteriorating Patient Group leads on monitoring audit results regarding accurate completion of fluid balance charts with ward managers taking responsibility for their results and making improvement where required.” Source location 2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
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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 Provide clinical induction training on completing and reviewing fluid-balance charts daily.
Verbatim wording from the response “In addition, all our clinical staff complete clinical induction days to ensure they understand the importance of completing fluid balance charts and reviewing these daily and our critical care outreach teams provide support and teaching to ward staff on the importance of completing fluid balance.
This concludes our response to your concern.” Source location 2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
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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 Support clinical leadership teams to understand roles and responsibilities for accurate fluid-balance monitoring.
Verbatim wording from the response “The Trust is focused on improving how we monitor fluid balance through the completion of fluid balance charts in all areas of the Trust. We have addressed this through supporting our clinical leadership teams in understanding their roles and responsibilities to ensure best practice in their wards by medical and nursing teams. We have undertaken multi-disciplinary education programmes on the importance of accurate fluid balance monitoring and regularly audit of the completion of fluid balance charts.
Our Deteriorating Patient Group leads on monitoring audit results regarding accurate completion of fluid balance charts with ward managers taking responsibility for their results and making improvement where required.” Source location 2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
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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 fluid-balance chart completion and monitor results through the Deteriorating Patient Group, with ward managers responsible for improvement.
Verbatim wording from the response “The Trust is focused on improving how we monitor fluid balance through the completion of fluid balance charts in all areas of the Trust. We have addressed this through supporting our clinical leadership teams in understanding their roles and responsibilities to ensure best practice in their wards by medical and nursing teams. We have undertaken multi-disciplinary education programmes on the importance of accurate fluid balance monitoring and regularly audit of the completion of fluid balance charts.
Our Deteriorating Patient Group leads on monitoring audit results regarding accurate completion of fluid balance charts with ward managers taking responsibility for their results and making improvement where required.” Source location 2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
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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 Provide ward staff with critical-care outreach support and teaching on completing fluid-balance charts.
Verbatim wording from the response “In addition, all our clinical staff complete clinical induction days to ensure they understand the importance of completing fluid balance charts and reviewing these daily and our critical care outreach teams provide support and teaching to ward staff on the importance of completing fluid balance.
This concludes our response to your concern.” Source location 2020-0112-Response-from-East-Kent-Hospitals-Trust.pdf
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2 Mar 2020 HARRY RICHFORD · Prevention of Future Deaths report North East Kent
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Concerns raised 20 Lack of cross-site clinical working opportunities View source Failure to notify the Coroner of a child death View source Uncertain auditing and logging of neonatal resuscitation pro forma completion View source Unclear guidance for obtaining anaesthetic help in paediatric emergencies View source Failure to retain placentae for examination after severe foetal distress View source Lack of clear requirements for consultant assessment of locum competence before overnight responsibility View source Failure to produce timely and sufficiently detailed statements after deaths View source Failure to assess and supervise locum clinicians View source Lack of clarity about when to call a consultant at night View source Failure to record consultant telephone advice View source Failure to record feedback and audit locum recruitment View source Insufficient consultant availability for night-time emergencies View source Lack of staff knowledge of applicable clinical guidelines and policies View source Failure to share important independent safety reports with staff View source Lack of paediatric team knowledge of neonatal collapse guidelines View source Lack of clarity about prompt action in obstetric emergencies View source Substandard obstetric record keeping View source Inaccurate and incomplete child death notification forms View source Inadequate neonatal resuscitation training View source Inaccurate MBRRACE maternal and neonatal death reporting View source See 17 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
HARRY RICHFORD · 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
Harry Richford was born at QEQM on 2 November 2017 and died at William Harvey Hospital on 9 November 2017 after being transferred there. The report describes delays in delivery, shortcomings in the caesarean delivery and neonatal resuscitation, and subsequent hypoxia and brain injury. Substantive concerns included locum recruitment, assessment and supervision; clarity about escalation to consultants; neonatal resuscitation training; record keeping and adherence to guidelines; and inaccurate death notifications and reporting.
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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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-site clinical working opportunities
Wider context from the report “Concern 8
Prior to Harry's death both ████████████████, a senior member of staff who had the care of Harry at the William Harvey Hospital, accepted that there were no opportunities for cross site working between QEQM and the William Harvey Hospital . Currently two out of eight middle grade doctors have had the opportunity to spend time at the William Harvey, which has a much higher specification neo natal unit. ████████ described the lack of opportunities before Harry's death as ‘at best, very surprising'.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the Coroner of a child death
Wider context from the report “Concern 17
The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected'. No notification was made to the Coroner . No details were filled in on the notification form giving any detail of the problems leading to Harry's death. As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Uncertain auditing and logging of neonatal resuscitation pro forma completion
Wider context from the report “Concern 15
The East Kent Trust should consider a review as to the use or otherwise of a resuscitation pro forma. A pro forma has since Harry's death been adopted by the East Kent Trust which, on the evidence of ████████, has improved the oversight of neo natal training and governance. It is not clear whether that pro forma is being audited or logged , or what actions are being done to ensure its completion and preservation.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear guidance for obtaining anaesthetic help in paediatric emergencies
Wider context from the report “Concern 9
The resuscitation of Harry was eventually carried out by ████████, the anaesthetist looking after ████████. His evidence was that leaving his own patient to help the paediatric team was an unusual action to take in the UK although he had often performed such actions in Nepal. Doctors at QEQM indicated that there was an informal policy that if a middle grade paediatrician found themselves in an emergency, they could seek help from their anaesthetic colleagues . It was unclear whether the anaesthetists were aware of this informal policy . This informal policy should be clarified, and guidance given because there is a risk, that in an emergency, it will be overlooked .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain placentae for examination after severe foetal distress
Wider context from the report “Concern 12
The placenta of Harry was not retained . Examination of the placenta will in some circumstances assist in cases of severe foetal distress. The Royal College of Pathologists states that it is 'essential' for the placenta to be sent for examination in cases of severe foetal distress requiring admission to a neo natal unit.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear requirements for consultant assessment of locum competence before overnight responsibility
Wider context from the report “Concern 2
The current policy of the East Kent Trust states that it is the responsibility of the healthcare professional who will be supervising the locum to assure themselves of his/her competence. This did not happen in this case. There is at present no requirement for a locum to be assessed on a day shift by a consultant before being left in charge overnight . There is no clear direction that it is the responsibility of the assessing consultant to satisfy themselves of the locum's experience and capability . One specialist from outside the East Kent Trust, ████████, also stated that it would assist the assessing consultants to be able to see not only the locum's CV but also their references and any training records 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to produce timely and sufficiently detailed statements after deaths
Wider context from the report “Concern 16
In order to try to prevent future deaths it is important that there are clear records and statements made when a death occurs so that lessons can be learnt. In this instance many of the statements were very scanty in their content and some were made a long time after the event . In some instances, staff had to make statements from memory without the advantage of seeing the medical notes . Contemporaneous (or as near as possible) notes are also very much in the interests of the staff involved so that they can give clear accounts of their actions and reasons for them if required to do so at a later date.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and supervise locum clinicians
Wider context from the report “Concern 1
████████ was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital . This was not an emergency appointment after, for example, a doctor calling in sick at the last minute. ████████ gave evidence that the recruitment, assessment and supervision of locums is a national problem and that there is a need for a review on a national level. This raises concerns that there may be a risk to other lives both at this trust and at other trusts in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about when to call a consultant at night
Wider context from the report “Concern 5
There appeared to be from the evidence given at the inquest substantial confusion amongst staff as to when a consultant should be called at night . The East Kent Trust now has some 70 hours a week consultant attendance on the wards. That leaves 14 hours a day when there is no consultant present. Staff, whether doctors, nurses or midwives should know the circumstances in which consultant help should be sought and should not feel inhibited from making their views known. If staff are unaware or unsure of when the consultant should be called that potentially poses a continuing risk to life.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record consultant telephone advice
Wider context from the report “Concern 14
There are no current records kept by consultants who are telephoned at home for advice . In this case there was a dispute about the number of calls made to ████████ and as to the content of these calls. The advice given and the actions taken as a result are important for the preservation of life.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record feedback and audit locum recruitment
Wider context from the report “Concern 3
████████ had worked two night time shifts at the QEQM before the night of Harry's birth. The extent to which there was any feedback from the consultants on call those two nights to ████████ is unclear. She, erroneously, believed the East Kent Trust had employed ████████. There is no record of any written feedback . From the evidence of the medical director of the East Kent Trust it appears that the current locum recruitment policy is not being checked or audited . There is a potential for further risks to life arising from these shortfalls.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient consultant availability for night-time emergencies
Wider context from the report “Concern 6
The current contracts at the East Kent Trust permit consultants to live up to 30 minutes travel time from the hospital . This poses considerable problems and risks for night time emergencies .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of applicable clinical guidelines and policies
Wider context from the report “Concern 10
There appeared to be considerable confusion among members of staff as to which, if any, guidelines and policies affected them . While two senior members of staff, ████████████████ (consultant), said that the East Kent Trust has systems in place to ensure knowledge of and compliance with Trust policies neither of them was able to say whether this was effective. Significant issues remain as to the knowledge of staff as to which guidelines govern their behaviour (this was also a finding of the Health and Safety Investigation Board in 2019). Such confusion or lack of knowledge increases the risk of future deaths.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share important independent safety reports with staff
Wider context from the report “Concern 19
Important independent reports do not appear to have been shared within the East Kent Trust's staff , for instance the HSIB report into Harry's death appeared during the inquest to be unknown to a number of the staff .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of paediatric team knowledge of neonatal collapse guidelines
Wider context from the report “Concern 11
There was a lack of knowledge within the paediatric team of guidelines issued by the Department of Women's Health . The evidence from the East Kent Trust doctors was that the guidelines issued by the department directed to 'all maternity and neonatal staff who may be involved with the immediate care and support of a collapsed neonate' would not have been known to the paediatric team at the relevant time. Even senior clinicians, such as ████████, were not aware of the relevant guidelines.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about prompt action in obstetric emergencies
Wider context from the report “Concern 4
There is a risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Substandard obstetric record keeping
Wider context from the report “Concern 13
The standard of record keeping on the obstetric unit was substantially sub-standard . The quality of the note taking and records is of considerable importance to new staff taking over responsibility for mother and baby. Without there being clear accurate records there is a risk of further mistakes being made leading, at the worst, to the risk of death. An example of this in Harry's case is that the record of the syntocinon prescribed to ████████ over a long period of time is inconsistent with the evidence of the midwives and the registrar who gave it to her.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and incomplete child death notification forms
Wider context from the report “Concern 17
The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected' . No notification was made to the Coroner. No details were filled in on the notification form giving any detail of the problems leading to Harry's death . As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate neonatal resuscitation training
Wider context from the report “Concern 7
The evidence of ████████ raised substantial concerns about the quality of training and learning in respect of neonatal resuscitation at the East Kent Trust. His evidence was that it would be desirable for middle grade doctors to attend the ARNI course (the advanced resuscitation of the new born infant). He also recommended that there should be simulated drills in neo natal resuscitation.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate MBRRACE maternal and neonatal death reporting
Wider context from the report “Concern 18
The MBRRACE form in respect of Harry Richford was inaccurate in a number of important areas . The form is important to provide robust national data to support the delivery of safe, high quality maternal and new born care as well as identifying errors and faults, if any, where there has been a maternal or infant death so that future deaths can be avoided.
” Open source report
15 May 2019 Mildred CLARK · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 3 Pressure on staff to avoid hospital admission View source Failure to assess painful, swollen and hard suspected hernias for strangulation and arrange hospital transfer View source Failure to ensure paramedics are not instructed to reduce hernias outside their training View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mildred 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
Mildred CLARK died in hospital on 17 December 2017 following infection and failure of a bypass graft, haemorrhage, and inadequate blood supply to the leg. The inquest found that delay in diagnosing the infection and haematoma limited the available medical intervention. A separate concern was raised about a paramedic being instructed by telephone to attempt hernia reduction despite not being trained to do so, and about possible pressure on staff to avoid hospital admission during winter pressure.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Pressure on staff to avoid hospital admission
Wider context from the report “Although this matter did not contribute to this death a concern was raised that a paramedic sought telephone advice from a hospital doctor by telephone on presenting symptoms and the initial diagnosis was that of a hernia were was extreme pain. The paramedic was instructed to carry out a procedure to reduce the hernia despite being informed that the paramedic was not trained to do so. The attempt caused extreme pain and failed.
(1) A senior member of ambulance crew gave evidence that reducing a hernia was not the role of a paramedic and a doctor should not instruct a paramedic to carry out this procedure particularly when they have stated they are not trained.
(2) A consultant surgeon gave evidence that:
a. a suspected hernia is not a medical emergency and there was no pressing requirement to undertake the procedure that could lead to complications if incorrectly carried out
b. where there is pain, swelling and hardness as in this case, if a hernia is suspected it would be reasonable to consider if this was a case of strangulated hernia as this could be a medical emergency and an attempt to reduce it cause significant complications and a patient should be taken to hospital
(3) There was a concern raised that staff may have felt pressured to act to avoid hospital admission during a period of winter pressure
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess painful, swollen and hard suspected hernias for strangulation and arrange hospital transfer
Wider context from the report “Although this matter did not contribute to this death a concern was raised that a paramedic sought telephone advice from a hospital doctor by telephone on presenting symptoms and the initial diagnosis was that of a hernia were was extreme pain. The paramedic was instructed to carry out a procedure to reduce the hernia despite being informed that the paramedic was not trained to do so. The attempt caused extreme pain and failed.
(1) A senior member of ambulance crew gave evidence that reducing a hernia was not the role of a paramedic and a doctor should not instruct a paramedic to carry out this procedure particularly when they have stated they are not trained.
(2) A consultant surgeon gave evidence that:
a. a suspected hernia is not a medical emergency and there was no pressing requirement to undertake the procedure that could lead to complications if incorrectly carried out
b. where there is pain, swelling and hardness as in this case, if a hernia is suspected it would be reasonable to consider if this was a case of strangulated hernia as this could be a medical emergency and an attempt to reduce it cause significant complications and a patient should be taken to hospital
(3) There was a concern raised that staff may have felt pressured to act to avoid hospital admission during a period of winter pressure
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure paramedics are not instructed to reduce hernias outside their training
Wider context from the report “Although this matter did not contribute to this death a concern was raised that a paramedic sought telephone advice from a hospital doctor by telephone on presenting symptoms and the initial diagnosis was that of a hernia were was extreme pain. The paramedic was instructed to carry out a procedure to reduce the hernia despite being informed that the paramedic was not trained to do so . The attempt caused extreme pain and failed.
(1) A senior member of ambulance crew gave evidence that reducing a hernia was not the role of a paramedic and a doctor should not instruct a paramedic to carry out this procedure particularly when they have stated they are not trained .
(2) A consultant surgeon gave evidence that:
a. a suspected hernia is not a medical emergency and there was no pressing requirement to undertake the procedure that could lead to complications if incorrectly carried out
b. where there is pain, swelling and hardness as in this case, if a hernia is suspected it would be reasonable to consider if this was a case of strangulated hernia as this could be a medical emergency and an attempt to reduce it cause significant complications and a patient should be taken to hospital
(3) There was a concern raised that staff may have felt pressured to act to avoid hospital admission during a period of winter pressure
” Open source report
Concerns raised 8 Failure to complete, review and enforce falls risk assessments View source Failure to address falls risk at handover View source Failure to make referrals to the falls team or physiotherapy View source Failure to address and follow up escalated falls-prevention concerns View source Failure to recognise and implement required fall-prevention interventions View source Failure to ensure bed-rail use follows bed-rail risk assessments View source Unavailability of observable beds and crash mats for patients requiring them View source Failure to document falls risk assessments and fall-prevention interventions View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Blakeney KING · 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
Peter Blakeney King was admitted to hospital with confusion, headache, fever and limb weakness, and later fell from his bed on 18 March 2017, sustaining fatal head injuries. The concerns included inadequate documentation and implementation of falls precautions, use of bed rails despite an assessment that they were not recommended, failure to provide an observable bed and crash mat, and failure to address falls risk at handover.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete, review and enforce falls risk assessments
Wider context from the report “(1) Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William Harvey Hospital. Common to each was the fact that the death was caused as a result of a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced . Inquests in respect of each of the deaths have been held, the last in November 2017. The Trust was given an opportunity following the earlier inquests to provide evidence of changes to practice following the deaths. It is recognised that at the time of hearing the inquests much work has already been done to address these issues but that work is ongoing and parts of that work have not yet been implemented/were in the process of being implemented. It is for this reason that Regulation 28 reports arise from three of the deaths.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address falls risk at handover
Wider context from the report “(5) Falls risk was not addressed at handover
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make referrals to the falls team or physiotherapy
Wider context from the report “(2) In respect of Mr King a falls risk assessment and precautions to minimise the risk of falls was not properly documented; interventions were not recorded and no referrals were made to either the falls team or physiotherapy . A bed rails risk assessment was completed which recorded that bed rails were not recommended but were in use at the time of the 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 East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address and follow up escalated falls-prevention concerns
Wider context from the report “(3) When Mr King was transferred to Cambridge ward from the clinical decision unit the receiving nurse recognised that Mr King should have been nursed in an observable bed with a crash mat and as neither were available on the ward, escalated the matter to the site co-ordinator. There was no evidence that these concerns were ever addressed by the site co-ordinator or followed up by nursing staff
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and implement required fall-prevention interventions
Wider context from the report “(4) A review of the falls risk assessment and bed rails assessment was recorded, however the fact that interventions were required to prevent the risk of falls was either not recognised or not implemented .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure bed-rail use follows bed-rail risk assessments
Wider context from the report “(2) In respect of Mr King a falls risk assessment and precautions to minimise the risk of falls was not properly documented; interventions were not recorded and no referrals were made to either the falls team or physiotherapy. A bed rails risk assessment was completed which recorded that bed rails were not recommended but were in use at the time of the 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 East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of observable beds and crash mats for patients requiring them
Wider context from the report “(3) When Mr King was transferred to Cambridge ward from the clinical decision unit the receiving nurse recognised that Mr King should have been nursed in an observable bed with a crash mat and as neither were available on the ward , escalated the matter to the site co-ordinator. There was no evidence that these concerns were ever addressed by the site co-ordinator or followed up by nursing staff
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document falls risk assessments and fall-prevention interventions
Wider context from the report “(2) In respect of Mr King a falls risk assessment and precautions to minimise the risk of falls was not properly documented ; interventions were not recorded and no referrals were made to either the falls team or physiotherapy. A bed rails risk assessment was completed which recorded that bed rails were not recommended but were in use at the time of the fall.
” 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 Falls Risk Assessment and Care Plan to align it explicitly with NICE falls-prevention guidance.
Verbatim wording from the response “There are no published studies of falls risk prediction tools that predicted risk at greater than 70% sensitivity. The National Institute Health and Care Excellence (NICE) therefore concluded that all inpatients aged 65 and older ‘should have their care managed as if they are at risk of falling’ on the basis that these patients ‘often have newly acquired risk factors (such as acute illness, delirium, cardiovascular disease, impaired mobility, medication or syncope syndrome) and are exposed to unfamiliar surroundings, which puts them at increased risk of falling during their inpatient stay’.¹ The current falls policy and risk assessment tool reflect NICE guidance and we have focused on these areas specifically in order to action the factors that are known to reduce falls risk.” Source location 2017-0414-Response-by-East-Kent-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The current falls policy and risk assessment tool reflect NICE guidance and address known factors that reduce inpatient falls risk.
Verbatim wording from the response “There are no published studies of falls risk prediction tools that predicted risk at greater than 70% sensitivity. The National Institute Health and Care Excellence (NICE) therefore concluded that all inpatients aged 65 and older ‘should have their care managed as if they are at risk of falling’ on the basis that these patients ‘often have newly acquired risk factors (such as acute illness, delirium, cardiovascular disease, impaired mobility, medication or syncope syndrome) and are exposed to unfamiliar surroundings, which puts them at increased risk of falling during their inpatient stay’.¹ The current falls policy and risk assessment tool reflect NICE guidance and we have focused on these areas specifically in order to action the factors that are known to reduce falls risk.” Source location 2017-0414-Response-by-East-Kent-NHS-Trust
Open published response
Concerns raised 3 Inadequate monitoring and enforcement of falls prevention policies and procedures View source Failure to complete and review adequate falls risk assessments View source Inadequate policies and procedures for falls risk assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Harold Graham WONFOR · 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
Harold Graham Wonfor was admitted to hospital with confusion, reduced mobility and a history of falls, but no falls assessment or prevention measures were put in place before he suffered an unwitnessed fall and head injury. He sustained a subdural haematoma, declined and died on 30 January 2017. The principal concerns were inadequate falls-risk assessment for vulnerable patients and inadequate monitoring and enforcement of falls-prevention 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 East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate monitoring and enforcement of falls prevention policies and procedures
Wider context from the report “(3) There is inadequate monitoring and enforcement of the falls prevention policies and 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 East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and review adequate falls risk assessments
Wider context from the report “(1) Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William Harvey Hospital. Common to each was the fact that the death was caused as a result of a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced. Inquests in respect of each of the deaths have been held, the last in November 2017. The Trust was given an opportunity following the earlier inquests to provide evidence of changes to practice following the deaths. It is recognised that at the time of hearing the inquests much work has already been done to address these issues but that work is ongoing and parts of that work have not yet been implemented/were in the process of being implemented. It is for this reason that Regulation 28 reports arise from three of the deaths.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate policies and procedures for falls risk assessment
Wider context from the report “(2) That the policies and procedures for falls risk assessment is inadequate especially for the vulnerable
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue timely and adequate falls risk assessments for patients.
Verbatim wording from the response “We note this Regulation 28 Report to prevent future deaths is one of three Inquests heard by the Central and South East Coroners in September 2017 and the matters of concern relate to the management of falls within the Trust. Acknowledgement by the Senior Coroner of the improvements that have already been made by the Trust regarding timely and adequate falls risk assessments is gratefully received and this work continues as outlined in my response.” Source location 2017-0408-Response-East-Kent-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Falls Risk Assessment and Care Plan to explicitly incorporate relevant NICE falls-prevention guidance.
Verbatim wording from the response “There are no published studies of falls risk prediction tools that predicted risk at greater than 70% sensitivity. The National Institute Health and Care Excellence (NICE) therefore concluded that all inpatients aged 65 and older ‘should have their care managed as if they are at risk of falling’ on the basis that these patients ‘often have newly acquired risk factors (such as acute illness, delirium, cardiovascular disease, impaired mobility, medication or syncope syndrome) and are exposed to unfamiliar surroundings, which puts them at increased risk of falling during their inpatient stay’. The current falls policy and risk assessment tool reflect NICE guidance and we have focused on these areas specifically in order to action the factors that are known to reduce falls risk.” Source location 2017-0408-Response-East-Kent-NHS-Trust
Open published response
Concerns raised 4 Failure to implement required falls precautions View source Unclear bedrail risk assessments View source Failure to maintain adequate, complete, current and enforced falls risk assessments View source Inappropriate use of bed rails View source See 1 more concern
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
Henry George HONOUR · 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
Henry George Honour suffered an unwitnessed fall in hospital on 4 February 2017, sustaining a left hip fracture that was discovered four days later. He underwent surgery but died on 21 February 2017 from bronchopneumonia associated with immobility and the fracture. Concerns included inadequate falls-risk assessments, inappropriate use of bedrails, and failure to update the assessment or implement protective measures after the fall.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement required falls precautions
Wider context from the report “(1) Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William Harvey Hospital. Common to each was the fact that the death was caused as a result of a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced. Inquests in respect of each the deaths have been held, the last in November 2017. The Trust was given an opportunity following the earlier inquests to provide evidence of changes to practice following the deaths. It is recognised that at the time of hearing the inquests much work has already been done to address these issues but that work is ongoing and parts of that work have not yet been implemented/were in the process of being implemented. It is for this reason that Regulation 28 reports arise from three of the deaths.
(2) In respect of Mr Honour the falls risk assessment completed on admission was at best perfunctory, as were subsequent reviews which did not rectify earlier errors or recognise the need for precautionary measures to be taken when Mr. Honour should have been nursed in an observable bed with a falls alert and hip protectors in light of the risks posed.
(3) The bedrail risk assessment was difficult to interpret in light of the falls risk assessment, bed rails were utilised when they should not have been.
(4) The falls risk assessment was not updated post fall and no protective measures were put 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 East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear bedrail risk assessments
Wider context from the report “(1) Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William Harvey Hospital. Common to each was the fact that the death was caused as a result of a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced. Inquests in respect of each the deaths have been held, the last in November 2017. The Trust was given an opportunity following the earlier inquests to provide evidence of changes to practice following the deaths. It is recognised that at the time of hearing the inquests much work has already been done to address these issues but that work is ongoing and parts of that work have not yet been implemented/were in the process of being implemented. It is for this reason that Regulation 28 reports arise from three of the deaths.
(2) In respect of Mr Honour the falls risk assessment completed on admission was at best perfunctory, as were subsequent reviews which did not rectify earlier errors or recognise the need for precautionary measures to be taken when Mr. Honour should have been nursed in an observable bed with a falls alert and hip protectors in light of the risks posed.
(3) The bedrail risk assessment was difficult to interpret in light of the falls risk assessment , bed rails were utilised when they should not have been.
(4) The falls risk assessment was not updated post fall and no protective measures were put 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 East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate, complete, current and enforced falls risk assessments
Wider context from the report “(1) Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William Harvey Hospital. Common to each was the fact that the death was caused as a result of a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced . Inquests in respect of each the deaths have been held, the last in November 2017. The Trust was given an opportunity following the earlier inquests to provide evidence of changes to practice following the deaths. It is recognised that at the time of hearing the inquests much work has already been done to address these issues but that work is ongoing and parts of that work have not yet been implemented/were in the process of being implemented. It is for this reason that Regulation 28 reports arise from three of the deaths.
(2) In respect of Mr Honour the falls risk assessment completed on admission was at best perfunctory, as were subsequent reviews which did not rectify earlier errors or recognise the need for precautionary measures to be taken when Mr. Honour should have been nursed in an observable bed with a falls alert and hip protectors in light of the risks posed.
(3) The bedrail risk assessment was difficult to interpret in light of the falls risk assessment, bed rails were utilised when they should not have been.
(4) The falls risk assessment was not updated post fall and no protective measures were put 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 East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate use of bed rails
Wider context from the report “(1) Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William Harvey Hospital. Common to each was the fact that the death was caused as a result of a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced. Inquests in respect of each the deaths have been held, the last in November 2017. The Trust was given an opportunity following the earlier inquests to provide evidence of changes to practice following the deaths. It is recognised that at the time of hearing the inquests much work has already been done to address these issues but that work is ongoing and parts of that work have not yet been implemented/were in the process of being implemented. It is for this reason that Regulation 28 reports arise from three of the deaths.
(2) In respect of Mr Honour the falls risk assessment completed on admission was at best perfunctory, as were subsequent reviews which did not rectify earlier errors or recognise the need for precautionary measures to be taken when Mr. Honour should have been nursed in an observable bed with a falls alert and hip protectors in light of the risks posed.
(3) The bedrail risk assessment was difficult to interpret in light of the falls risk assessment, bed rails were utilised when they should not have been .
(4) The falls risk assessment was not updated post fall and no protective measures were put in place.
” Open source report
8 May 2017 Andrew Jonathan WILSON · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 5 Lack of arrangements to provide peritoneal dialysis at hospitals other than the renal unit View source Unavailability of equipment for peritoneal dialysis View source Failure of treating clinicians to know when peritoneal dialysis cannot be arranged at the hospital View source Unavailability of trained staff to provide peritoneal dialysis View source Lack of arrangements to transport peritoneal dialysis equipment from a patient's home to hospital View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Andrew Jonathan WILSON · 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
Andrew Jonathan Wilson had end-stage renal failure managed with home peritoneal dialysis and was admitted to Maidstone Hospital with sepsis on 20 July 2015. Peritoneal dialysis was unavailable at Maidstone Hospital and its satellite renal unit for three nights before he was transferred to the Kent and Canterbury Hospital, where dialysis was recommenced. He later deteriorated and died of natural causes; concerns were raised about the lack of arrangements, trained staff, equipment, and clinician awareness needed to provide peritoneal dialysis outside the Canterbury renal unit.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of arrangements to provide peritoneal dialysis at hospitals other than the renal unit
Wider context from the report “(1) Although it was established on the balance of probability (after hearing the clinicians and an independent expert Consultant Nephrologist) that the absence of peritoneal dialysis on THIS occasion did not contribute to the death, the absence of any arrangements to provide peritoneal dialysis at hospitals other than the renal unit at Canterbury raised a concern.
(2) There was an apparent absence of knowledge on the part of the treating clinicians at Maidstone Hospital that peritoneal dialysis could not be arranged either during the day or over-night at that hospital as there were no trained staff available nor was the equipment available. There were no arrangements in place to transport the equipment from the home of a patient to the hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of equipment for peritoneal dialysis
Wider context from the report “(1) Although it was established on the balance of probability (after hearing the clinicians and an independent expert Consultant Nephrologist) that the absence of peritoneal dialysis on THIS occasion did not contribute to the death, the absence of any arrangements to provide peritoneal dialysis at hospitals other than the renal unit at Canterbury raised a concern.
(2) There was an apparent absence of knowledge on the part of the treating clinicians at Maidstone Hospital that peritoneal dialysis could not be arranged either during the day or over-night at that hospital as there were no trained staff available nor was the equipment available . There were no arrangements in place to transport the equipment from the home of a patient to the hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of treating clinicians to know when peritoneal dialysis cannot be arranged at the hospital
Wider context from the report “(1) Although it was established on the balance of probability (after hearing the clinicians and an independent expert Consultant Nephrologist) that the absence of peritoneal dialysis on THIS occasion did not contribute to the death, the absence of any arrangements to provide peritoneal dialysis at hospitals other than the renal unit at Canterbury raised a concern.
(2) There was an apparent absence of knowledge on the part of the treating clinicians at Maidstone Hospital that peritoneal dialysis could not be arranged either during the day or over-night at that hospital as there were no trained staff available nor was the equipment available. There were no arrangements in place to transport the equipment from the home of a patient to the hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of trained staff to provide peritoneal dialysis
Wider context from the report “(1) Although it was established on the balance of probability (after hearing the clinicians and an independent expert Consultant Nephrologist) that the absence of peritoneal dialysis on THIS occasion did not contribute to the death, the absence of any arrangements to provide peritoneal dialysis at hospitals other than the renal unit at Canterbury raised a concern.
(2) There was an apparent absence of knowledge on the part of the treating clinicians at Maidstone Hospital that peritoneal dialysis could not be arranged either during the day or over-night at that hospital as there were no trained staff available nor was the equipment available. There were no arrangements in place to transport the equipment from the home of a patient to the hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of arrangements to transport peritoneal dialysis equipment from a patient's home to hospital
Wider context from the report “(1) Although it was established on the balance of probability (after hearing the clinicians and an independent expert Consultant Nephrologist) that the absence of peritoneal dialysis on THIS occasion did not contribute to the death, the absence of any arrangements to provide peritoneal dialysis at hospitals other than the renal unit at Canterbury raised a concern.
(2) There was an apparent absence of knowledge on the part of the treating clinicians at Maidstone Hospital that peritoneal dialysis could not be arranged either during the day or over-night at that hospital as there were no trained staff available nor was the equipment available. There were no arrangements in place to transport the equipment from the home of a patient to the hospital .
” Open source report
Concerns raised 5 Delay in operating to remove bowel obstruction View source Delay in confirming sigmoid colon obstruction diagnosis View source Delay in deciding on stenting for bowel obstruction View source Delays in surgery following cancer diagnosis View source Delays in cancer diagnosis View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Helen Jennifer Turner · 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
Helen Jennifer Turner was admitted with diarrhoea and vomiting and was diagnosed with a sigmoid colon obstruction. She later developed sepsis, colonic perforation and peritonitis, underwent surgery and further procedures, and died after her condition deteriorated. The report identified delays in confirming the obstruction, arranging stenting and operating to remove it; expert evidence stated that these delays diminished her chances of survival.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in operating to remove bowel obstruction
Wider context from the report “• There was a delay in operating on Mrs Turner to remove the bowel obstruction which did not take place until 20.04.15 by which stage her condition had deteriorated to a critical level.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in confirming sigmoid colon obstruction diagnosis
Wider context from the report “• There was a delay in confirming the diagnosis of sigmoid colon obstruction which did not take place until 12.04.15, some four days after her admission to William Harvey Hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in deciding on stenting for bowel obstruction
Wider context from the report “• There was a delay in the decision for Mrs Turner to undergo a stenting of four days , by which time her condition had deteriorated thus rendering her unsuitable for this procedure.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in surgery following cancer diagnosis
Wider context from the report “• The expert evidence heard at the Inquest found that Mrs Turner had a 90% chance of surviving the diagnosis of cancer and abdominal surgery to remove the tumour. Because of the delay in diagnosis and surgery , her chances of survival were diminished.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in cancer diagnosis
Wider context from the report “• The expert evidence heard at the Inquest found that Mrs Turner had a 90% chance of surviving the diagnosis of cancer and abdominal surgery to remove the tumour. Because of the delay in diagnosis and surgery , her chances of survival were diminished.
” Open source report
Concerns raised 1 Failure to consider necessary action in light of trauma, multiple fractured ribs and anticoagulation-related internal bleeding risk View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patricia Anne HOLMES · 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
Patricia Anne Holmes was diagnosed with fractured ribs at William Harvey Hospital on 1 February 2015 and, despite information that she was receiving anticoagulation therapy with an INR of 6, no action was taken to reverse its effect. She returned in a state of collapse on 2 February and died two days later; the principal concern was that the treating A&E doctor did not consider the risk of internal bleeding associated with her trauma, rib fractures and anticoagulation therapy.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider necessary action in light of trauma, multiple fractured ribs and anticoagulation-related internal bleeding risk
Wider context from the report “The staff grade A&E doctor who treated Mrs Holmes on 1 February did not consider what action was necessary given the history of trauma and multiple fractured ribs on x-ray and that she was at risk of internal bleeding since she was receiving anticoagulation therapy .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the approved Chest Trauma Algorithm across the Trust’s emergency departments to guide triage, assessment, treatment, anticoagulation reversal and haematology advice.
Verbatim wording from the response “Prior to the inquest being resumed, the Trust had already disclosed to you a draft Chest Trauma Algorithm and this has been approved and is now in place throughout the emergency departments of the Trust. The aim of the Algorithm is to safely triage, assess and treat patients who present with chest trauma. It has been designed to consider the reversal of anticoagulation, Box 1, of the Algorithm specifically directs the reader to consider the reversal of anticoagulation and to seek expert advice from the Trust's haematologists upon advice from the haematology committee on treatment within the Algorithm.” Source location 2015-0254-Response-by-East-Kent-University-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing mitigation focuses on chest injuries rather than extending the response to all trauma-related injuries.
Verbatim wording from the response “Mrs Holmes' case related to a chest trauma and the effects of the anticoagulant medication (Acenocoumarol) with her injuries. The Emergency Department and Surgical staff have therefore looked at mitigating similar events for future patients who present with chest injuries rather than all trauma-related injuries.” Source location 2015-0254-Response-by-East-Kent-University-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation An existing trauma protocol is considered more appropriate than a medication-specific anticoagulation pathway.
Verbatim wording from the response “Within your Regulation 28 Report dated 29 June 2015 you recommended that the Trust should have a protocol in place for the use of an anticoagulation pathway in all cases where a patient has sustained trauma and is in receipt of this type of medication. In view of the importance of maintaining clinical trauma and in respect of this type of medication, the Trust has a protocol which is used to assist and guide the management of patients with trauma. This is more appropriate than a protocol related to a specific type of medication.” Source location 2015-0254-Response-by-East-Kent-University-Hospitals-NHS-Trust
Open published response
Concerns raised 2 Failure to liaise with the tertiary centre about prior procedures View source Failure to act on clinically relevant email communication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kelly Patrick WILLIS · 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
Kelly Patrick Willis underwent atrial ablation at St Thomas’ Hospital on 8 October 2012 and was subsequently admitted to William Harvey Hospital several times with symptoms of general unwellness. He died from cerebral infarction, multiple septic emboli and an atrio-oesophageal fistula complicating the ablation. The principal concerns were delays in contacting the tertiary centre and failure to act on an email advising that complications should be considered and investigated.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to liaise with the tertiary centre about prior procedures
Wider context from the report “Those caring for Mr Willis at William Harvey Hospital recognised the need to contact St Thomas’ Hospital about the procedure that he had undergone there but failed to liaise with the tertiary centre before 29th October , even though this was well documented in the medical records on the first and third admissions that it should be. I am of the opinion that contact with the tertiary centre which had operated on Mr Willis should have been made when he first presented at William Harvey Hospital on 14th October, and thereafter on 22nd October and on 25th October as Dr ████████ had requested.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on clinically relevant email communication
Wider context from the report “Dr ████████ did not act on the email sent to her by Dr ████████ . Had she liaised with him it is likely, given his flu-like illness and increasing white cell count, that he would have been investigated with CT imaging either at St Thomas’ Hospital or William Harvey Hospital at an earlier stage than 29th October, thus allowing the opportunity to Dr ████████ to exclude rare complications, as he requested in his email to Dr ████████.
” 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 Publish and electronically disseminate a Risk Wise article reminding staff to reassess outstanding actions and consider contacting tertiary centres for guidance.
Verbatim wording from the response “In order to bring your concerns to the attention of the clinical and nursing staff within the Trust an article will be included in the regular publication produced by the central Risk Management Team entitled Risk Wise. This publication is disseminated electronically to all members of Trust staff and is produced on a quarterly basis. The article will include reminders to all staff of the importance of ensuring that requested actions which are either documented within the healthcare records or advised of during handover sessions, and which appear to be outstanding at the time of review are reassessed with a view to subsequent completion. The article will also inform the reader of the importance of considering the need to make contact with tertiary treatment centres for further guidance and patient management, particularly where a patient has already received treatment from that centre.” Source location 2015-0122-Response-by-East-Kent-Hospitals-University
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 Contact with tertiary centres is not necessary for all patients returning to the Trust, but is appropriate after rare procedural complications.
Verbatim wording from the response “appropriate or necessary for contact with tertiary centres to be made for all patients who subsequently return to our care, but it is appropriate in circumstances where patients suffer rare complications of procedures which they have undergone, such as in the case of Mr Willis. I fully understand that had timely contact been made with ████████ Mr Willis may have been offered further treatment for his condition and whilst the prognosis of long term survival would have been poor, he may have received alternative clinical care and management.” Source location 2015-0122-Response-by-East-Kent-Hospitals-University
Open published response
Concerns raised 4 Failure to secure an appropriate High Dependency Unit bed for a high-risk postoperative patient View source Inadequate pre-operative anaesthetic assessment of high-risk patients View source Insufficient staffed ITU bed capacity for patients requiring intensive therapy View source Failure to refer high-risk patients to a Tertiary Centre for second opinion and management View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Betty SMITH · 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
Betty SMITH underwent surgery for a large intrathoracic hiatus hernia on 22 October 2012, deteriorated the following day, was admitted to intensive care on 24 October, and died on 25 October from intraabdominal and intrathoracic haemorrhage following repair of the hiatus hernia. Concerns included the lack of a secured High Dependency Unit bed before surgery, inadequate anaesthetic pre-assessment and the failure to refer her to a tertiary centre. The report also identified reduced intensive care capacity due to closed beds and nursing shortages as compromising care.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to secure an appropriate High Dependency Unit bed for a high-risk postoperative patient
Wider context from the report “• To return Betty SMITH to a ward post-operatively and not secure an High Dependency Unit bed before surgery commenced falls well below accepted care. The expert opinion was concerned that such a high risk patient should have been referred to a Tertiary Centre for a second opinion and probably management.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate pre-operative anaesthetic assessment of high-risk patients
Wider context from the report “• The pre-assessment service offered by the Anaesthetic Department is far from adequate. To review such a high risk patient with significant comorbidity from the medical records is not in the patient’s interest. Time should be afforded to the anaesthetists to review the patient at an out-patient clinic pre-operatively to assess the risks and discuss them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffed ITU bed capacity for patients requiring intensive therapy
Wider context from the report “• Two ITU beds have been closed three months ago due to nursing shortages leaving William Harvey Hospital with just nine ITU beds . This is 4.5 beds per 100,000 population compared to the national average of 6.4 ITU beds. This is presenting the ITU Intensivists with significant difficulties and compromises the care of those patients requiring intensive therapy in a busy district general hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer high-risk patients to a Tertiary Centre for second opinion and management
Wider context from the report “• To return Betty SMITH to a ward post-operatively and not secure an High Dependency Unit bed before surgery commenced falls well below accepted care. The expert opinion was concerned that such a high risk patient should have been referred to a Tertiary Centre for a second opinion and probably management .
” Open source report
Concerns raised 9 Conservative management of left pneumothorax with antibiotics View source Failure to examine the patient immediately before right-lung aspiration View source Confusing medical-record format preventing sequential recording of entries View source Failure to request a chest X-ray before aspiration View source Failure to insert a chest drain for pneumothorax View source Failure to provide consultant on-call respiratory cover View source Inappropriate prescribing of gentamicin and aminophylline View source Failure to check radiology immediately before right-lung aspiration View source Failure to communicate consultant review findings to the medical on-call team View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Herbert Chandler · 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
Herbert Chandler was admitted to William Harvey Hospital with chronic obstructive pulmonary disease and a left pneumothorax. On 22 January 2013, an attempt to aspirate the left pneumothorax mistakenly aspirated the right lung first, after which the left lung was aspirated and he died soon afterwards. The concerns included the conservative management of the pneumothorax, medication prescribing, failures in clinical review and communication, the aspiration procedure, medical record format, and respiratory consultant cover.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Conservative management of left pneumothorax with antibiotics
Wider context from the report “A series of failings by the Trust have caused or contributed to the cause of death, namely:-
• A conservative approach to managing the left pneumothorax with antibiotics ,
• Inappropriate prescribing of medication, namely gentamicin and aminophylline,
• A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician,
• A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team,
• The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray,
• The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung,
The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology,
• A confusing format of medical records which prevented sequential recording of entries by health care professionals,
• A failure to provide Consultant on call respiratory cover.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to examine the patient immediately before right-lung aspiration
Wider context from the report “A series of failings by the Trust have caused or contributed to the cause of death, namely:-
• A conservative approach to managing the left pneumothorax with antibiotics,
• Inappropriate prescribing of medication, namely gentamicin and aminophylline,
• A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician,
• A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team,
• The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray,
• The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung,
The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology ,
• A confusing format of medical records which prevented sequential recording of entries by health care professionals,
• A failure to provide Consultant on call respiratory cover.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Confusing medical-record format preventing sequential recording of entries
Wider context from the report “A series of failings by the Trust have caused or contributed to the cause of death, namely:-
• A conservative approach to managing the left pneumothorax with antibiotics,
• Inappropriate prescribing of medication, namely gentamicin and aminophylline,
• A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician,
• A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team,
• The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray,
• The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung,
The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology,
• A confusing format of medical records which prevented sequential recording of entries by health care professionals ,
• A failure to provide Consultant on call respiratory cover.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to request a chest X-ray before aspiration
Wider context from the report “A series of failings by the Trust have caused or contributed to the cause of death, namely:-
• A conservative approach to managing the left pneumothorax with antibiotics,
• Inappropriate prescribing of medication, namely gentamicin and aminophylline,
• A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician,
• A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team,
• The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray ,
• The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung,
The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology,
• A confusing format of medical records which prevented sequential recording of entries by health care professionals,
• A failure to provide Consultant on call respiratory cover.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to insert a chest drain for pneumothorax
Wider context from the report “A series of failings by the Trust have caused or contributed to the cause of death, namely:-
• A conservative approach to managing the left pneumothorax with antibiotics,
• Inappropriate prescribing of medication, namely gentamicin and aminophylline,
• A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician,
• A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team,
• The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray,
• The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung,
The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology,
• A confusing format of medical records which prevented sequential recording of entries by health care professionals,
• A failure to provide Consultant on call respiratory cover.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consultant on-call respiratory cover
Wider context from the report “A series of failings by the Trust have caused or contributed to the cause of death, namely:-
• A conservative approach to managing the left pneumothorax with antibiotics,
• Inappropriate prescribing of medication, namely gentamicin and aminophylline,
• A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician,
• A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team,
• The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray,
• The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung,
The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology,
• A confusing format of medical records which prevented sequential recording of entries by health care professionals,
• A failure to provide Consultant on call respiratory cover .
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate prescribing of gentamicin and aminophylline
Wider context from the report “A series of failings by the Trust have caused or contributed to the cause of death, namely:-
• A conservative approach to managing the left pneumothorax with antibiotics,
• Inappropriate prescribing of medication, namely gentamicin and aminophylline ,
• A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician,
• A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team,
• The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray,
• The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung,
The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology,
• A confusing format of medical records which prevented sequential recording of entries by health care professionals,
• A failure to provide Consultant on call respiratory cover.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check radiology immediately before right-lung aspiration
Wider context from the report “A series of failings by the Trust have caused or contributed to the cause of death, namely:-
• A conservative approach to managing the left pneumothorax with antibiotics,
• Inappropriate prescribing of medication, namely gentamicin and aminophylline,
• A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician,
• A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team,
• The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray,
• The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung ,
The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology,
• A confusing format of medical records which prevented sequential recording of entries by health care professionals,
• A failure to provide Consultant on call respiratory cover.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate consultant review findings to the medical on-call team
Wider context from the report “A series of failings by the Trust have caused or contributed to the cause of death, namely:-
• A conservative approach to managing the left pneumothorax with antibiotics,
• Inappropriate prescribing of medication, namely gentamicin and aminophylline,
• A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician,
• A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team ,
• The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray,
• The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung,
The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology,
• A confusing format of medical records which prevented sequential recording of entries by health care professionals,
• A failure to provide Consultant on call respiratory cover.
” Open source report
14 Apr 2014 Nicos Andreas MICHAEL · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 5 Failure to transfer recorded medication allergy information across subsequent records and to GPs View source Medical reporting and patient-tracking systems failing to make known or suspected allergies readily available at presentation View source Failure to ensure checking of earlier paper records for allergy information View source Failure to ensure compulsory electronic prescribing for allergy checking View source Lack of clear recording of patients’ known or suspected medication allergies View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nicos Andreas MICHAEL · 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
Nicos Andreas MICHAEL died in hospital on 1 November 2013 after suffering a cardiac arrest and significant brain injury following an acute anaphylactic reaction to intravenously administered Augmentin. The principal concerns were that allergy information was conflicting or incompletely recorded, a historic hospital record of an Augmentin reaction was not carried forward or passed to the GP, and systems did not reliably make previous allergy information available to treating staff.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer recorded medication allergy information across subsequent records and to GPs
Wider context from the report “(1) There was no clear evidence (such as a document signed by Mr MICHAEL or a family member) detailing medication to which he/they was/were aware he was allergic. This led to there being conflicting evidence between his having (according to his son) highlighted his penicillin and Ibuprofen allergies to hospital staff and the allergy information for this admission recorded by hospital staff (which did not include penicillin but did include Ibuprofen).
(2) The Root Cause Analysis conducted by the hospital into this death identified that Mr MICHAEL had three sets of hospital notes, in one of which there was a solitary entry to suggest that at a past medical attendance a reaction to Augmentin was noted. That information does not appear to have been translated in any subsequent entries nor to have been passed to his GP .
(3)The importance of known or suspected allergies that have been recorded on previous contacts with a hospital being readily available to the hospital’s staff when next treating that patient cannot be over-emphasised. There was evidence that the RCA team have sought learning from this event and how to record accurately and continuously highlight all known allergies or reported allergies, and how that information can be kept and made available on every patient at presentation. However, the evidence also showed that the medical reporting and computer systems for patient tracking do not currently allow this facility in such a way, although the relevant Trust teams are investigating how this data recording can be made more accurate.
(4) Although the Trust has indicated that electronic prescribing should now be prioritised (which it considers could potentially have flagged up the historic allergy documentation), the RCA gave no indication that this would be compulsory for the future, or that any steps were being taken to encourage or make compulsory the checking of earlier paper records for information contained therein on allergies.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Medical reporting and patient-tracking systems failing to make known or suspected allergies readily available at presentation
Wider context from the report “(1) There was no clear evidence (such as a document signed by Mr MICHAEL or a family member) detailing medication to which he/they was/were aware he was allergic. This led to there being conflicting evidence between his having (according to his son) highlighted his penicillin and Ibuprofen allergies to hospital staff and the allergy information for this admission recorded by hospital staff (which did not include penicillin but did include Ibuprofen).
(2) The Root Cause Analysis conducted by the hospital into this death identified that Mr MICHAEL had three sets of hospital notes, in one of which there was a solitary entry to suggest that at a past medical attendance a reaction to Augmentin was noted. That information does not appear to have been translated in any subsequent entries nor to have been passed to his GP.
(3)The importance of known or suspected allergies that have been recorded on previous contacts with a hospital being readily available to the hospital’s staff when next treating that patient cannot be over-emphasised. There was evidence that the RCA team have sought learning from this event and how to record accurately and continuously highlight all known allergies or reported allergies, and how that information can be kept and made available on every patient at presentation. However, the evidence also showed that the medical reporting and computer systems for patient tracking do not currently allow this facility in such a way, although the relevant Trust teams are investigating how this data recording can be made more accurate.
(4) Although the Trust has indicated that electronic prescribing should now be prioritised (which it considers could potentially have flagged up the historic allergy documentation), the RCA gave no indication that this would be compulsory for the future, or that any steps were being taken to encourage or make compulsory the checking of earlier paper records for information contained therein on allergies.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure checking of earlier paper records for allergy information
Wider context from the report “(1) There was no clear evidence (such as a document signed by Mr MICHAEL or a family member) detailing medication to which he/they was/were aware he was allergic. This led to there being conflicting evidence between his having (according to his son) highlighted his penicillin and Ibuprofen allergies to hospital staff and the allergy information for this admission recorded by hospital staff (which did not include penicillin but did include Ibuprofen).
(2) The Root Cause Analysis conducted by the hospital into this death identified that Mr MICHAEL had three sets of hospital notes, in one of which there was a solitary entry to suggest that at a past medical attendance a reaction to Augmentin was noted. That information does not appear to have been translated in any subsequent entries nor to have been passed to his GP.
(3)The importance of known or suspected allergies that have been recorded on previous contacts with a hospital being readily available to the hospital’s staff when next treating that patient cannot be over-emphasised. There was evidence that the RCA team have sought learning from this event and how to record accurately and continuously highlight all known allergies or reported allergies, and how that information can be kept and made available on every patient at presentation. However, the evidence also showed that the medical reporting and computer systems for patient tracking do not currently allow this facility in such a way, although the relevant Trust teams are investigating how this data recording can be made more accurate.
(4) Although the Trust has indicated that electronic prescribing should now be prioritised (which it considers could potentially have flagged up the historic allergy documentation), the RCA gave no indication that this would be compulsory for the future, or that any steps were being taken to encourage or make compulsory the checking of earlier paper records for information contained therein on allergies.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure compulsory electronic prescribing for allergy checking
Wider context from the report “(1) There was no clear evidence (such as a document signed by Mr MICHAEL or a family member) detailing medication to which he/they was/were aware he was allergic. This led to there being conflicting evidence between his having (according to his son) highlighted his penicillin and Ibuprofen allergies to hospital staff and the allergy information for this admission recorded by hospital staff (which did not include penicillin but did include Ibuprofen).
(2) The Root Cause Analysis conducted by the hospital into this death identified that Mr MICHAEL had three sets of hospital notes, in one of which there was a solitary entry to suggest that at a past medical attendance a reaction to Augmentin was noted. That information does not appear to have been translated in any subsequent entries nor to have been passed to his GP.
(3)The importance of known or suspected allergies that have been recorded on previous contacts with a hospital being readily available to the hospital’s staff when next treating that patient cannot be over-emphasised. There was evidence that the RCA team have sought learning from this event and how to record accurately and continuously highlight all known allergies or reported allergies, and how that information can be kept and made available on every patient at presentation. However, the evidence also showed that the medical reporting and computer systems for patient tracking do not currently allow this facility in such a way, although the relevant Trust teams are investigating how this data recording can be made more accurate.
(4) Although the Trust has indicated that electronic prescribing should now be prioritised (which it considers could potentially have flagged up the historic allergy documentation), the RCA gave no indication that this would be compulsory for the future , or that any steps were being taken to encourage or make compulsory the checking of earlier paper records for information contained therein on allergies.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear recording of patients’ known or suspected medication allergies
Wider context from the report “(1) There was no clear evidence (such as a document signed by Mr MICHAEL or a family member) detailing medication to which he/they was/were aware he was allergic . This led to there being conflicting evidence between his having (according to his son) highlighted his penicillin and Ibuprofen allergies to hospital staff and the allergy information for this admission recorded by hospital staff (which did not include penicillin but did include Ibuprofen) .
(2) The Root Cause Analysis conducted by the hospital into this death identified that Mr MICHAEL had three sets of hospital notes, in one of which there was a solitary entry to suggest that at a past medical attendance a reaction to Augmentin was noted. That information does not appear to have been translated in any subsequent entries nor to have been passed to his GP.
(3)The importance of known or suspected allergies that have been recorded on previous contacts with a hospital being readily available to the hospital’s staff when next treating that patient cannot be over-emphasised. There was evidence that the RCA team have sought learning from this event and how to record accurately and continuously highlight all known allergies or reported allergies, and how that information can be kept and made available on every patient at presentation. However, the evidence also showed that the medical reporting and computer systems for patient tracking do not currently allow this facility in such a way, although the relevant Trust teams are investigating how this data recording can be made more accurate.
(4) Although the Trust has indicated that electronic prescribing should now be prioritised (which it considers could potentially have flagged up the historic allergy documentation), the RCA gave no indication that this would be compulsory for the future, or that any steps were being taken to encourage or make compulsory the checking of earlier paper records for information contained therein on allergies.
” Open source report
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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 records did not contain a consistently recorded penicillin allergy; staff were aware of the patient's reported allergies.
Verbatim wording from the response “1. There was no consistently recorded allergy to penicillin contained in the healthcare records held by the Trust. Indeed the patient himself did not articulate an allergy to penicillin at his pre-operative assessment; he did state allergies to Ibuprofen and Aspirin and red “known allergy” wristbands were applied from the date of his admission. The staff on ICU and on Kent Ward were all aware of Mr Michael’s reported allergies.” Source location 2014-0168-Response-by-East-Kent-Hospitals-University
Open published response
Concerns raised 2 Failure to carry out required second clinical observations View source Failure to escalate outstanding requests for surgical review View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
William Albert Winter · 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
William Albert Winter was admitted to hospital after discharge from St Thomas’ Hospital following surgery for repair of an abdominal aortic aneurysm, and was found unresponsive with rigor mortis at approximately 5am on 26th March 2013. Nursing staff were concerned that he had not been reviewed by the surgical team, and a second set of observations was not carried out or escalated as required amid pressures on the Clinical Decisions Unit.
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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out required second clinical observations
Wider context from the report “Mr Winter was admitted to the CDU at 8pm and the nursing staff were concerned that he had not been reviewed by the surgical team. They missed carrying out a second set of observations soon after 2am on 26th March 2013 owing to the pressures on them to care for other patients on the Clinical Decisions Unit. Mr Winter was found in an unresponsive state at approximately 5am on 26th March 2013 when efforts were made to resuscitate him during which it was noted that rigor mortis had already developed.
I heard evidence that there were 19 admissions and discharges to and from the CDU overnight with 4 members of nursing staff. It was apparent that whilst keeping an eye on Mr Winter, they did not carry out a second set of observations when they should have done nor did they escalate their request for a surgical review. They were unfamiliar with how to do this.
” 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 Kent Hospitals University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate outstanding requests for surgical review
Wider context from the report “Mr Winter was admitted to the CDU at 8pm and the nursing staff were concerned that he had not been reviewed by the surgical team . They missed carrying out a second set of observations soon after 2am on 26th March 2013 owing to the pressures on them to care for other patients on the Clinical Decisions Unit. Mr Winter was found in an unresponsive state at approximately 5am on 26th March 2013 when efforts were made to resuscitate him during which it was noted that rigor mortis had already developed.
I heard evidence that there were 19 admissions and discharges to and from the CDU overnight with 4 members of nursing staff. It was apparent that whilst keeping an eye on Mr Winter, they did not carry out a second set of observations when they should have done nor did they escalate their request for a surgical review . They were unfamiliar with how to do this .
” 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