Concerns raised 4 Inaccurate fluid balance charting failing to account for all sources of fluid provision View source Lack of a procedure requiring contact with the original treating department on readmission after recent surgery View source Failure to take unwitnessed seizure activity into account in Emergency Department assessment View source Lack of standard operating practice and training to ensure recent surgery is considered in Emergency Department triage 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
Adrienne Caroline STUDHOLME · 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
Adrienne Caroline STUDHOLME died on 23 September 2023 at Royal Blackburn Hospital after readmission following a left nephrectomy, with a spontaneous splenic haemorrhage and rupture identified later that day and subsequent myocardial infarction. The report states that her death was contributed to by a delay in diagnosing and treating the splenic rupture. Concerns included inaccurate fluid-balance charts, seizure activity not being considered unless witnessed by staff, and the absence of procedures, standard operating practice, and training to ensure recent surgery was considered and communicated during emergency-department triage.
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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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate fluid balance charting failing to account for all sources of fluid provision
Wider context from the report “(1) The fluid balance chart was found to be inaccurate . The evidence suggested that the accuracy of the chart relied on staff collecting and refilling empty water jugs and took no account of steps families may take to provide fluid
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure requiring contact with the original treating department on readmission after recent surgery
Wider context from the report “(3) Evidence was heard that on readmission via the Emergency Department following recent surgery, there is no procedure requiring contact with the original treating department . In addition, there is no standard operating practice and no training ensuring that recent surgery is taken into account in a triage in the Emergency department.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to take unwitnessed seizure activity into account in Emergency Department assessment
Wider context from the report “(2) Evidence was heard that seizure activity would not be taken into account in assessing a patient in the Emergency Department unless it was witnessed by a member of 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of standard operating practice and training to ensure recent surgery is considered in Emergency Department triage
Wider context from the report “(3) Evidence was heard that on readmission via the Emergency Department following recent surgery, there is no procedure requiring contact with the original treating department. In addition, there is no standard operating practice and no training ensuring that recent surgery is taken into account in a triage in the Emergency department .
” 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 Monitor implementation of revised professional standards through internal assurance processes, escalating issues to the Quality Committee until embedded in business as usual.
Verbatim wording from the response “It is accepted, however, that where clinical judgement indicates the possibility that a direct surgical complication may have arisen, then urgent contact with the surgical team is essential. Clinicians from the ED have been reminded of the importance of this, and clinicians from the surgical teams of the importance of prompt response. Indeed, a revised version of our internal professional standards for response has been developed, and the Trust commits to monitor these once implemented.” Source location Response from East Lancashire NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop revised internal professional standards for response to support prompt surgical-team responses.
Verbatim wording from the response “It is accepted, however, that where clinical judgement indicates the possibility that a direct surgical complication may have arisen, then urgent contact with the surgical team is essential. Clinicians from the ED have been reminded of the importance of this, and clinicians from the surgical teams of the importance of prompt response. Indeed, a revised version of our internal professional standards for response has been developed, and the Trust commits to monitor these once implemented.” Source location Response from East Lancashire NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind Emergency Department and surgical clinicians to urgently contact the surgical team when clinical judgement indicates a possible surgical complication.
Verbatim wording from the response “It is accepted, however, that where clinical judgement indicates the possibility that a direct surgical complication may have arisen, then urgent contact with the surgical team is essential. Clinicians from the ED have been reminded of the importance of this, and clinicians from the surgical teams of the importance of prompt response. Indeed, a revised version of our internal professional standards for response has been developed, and the Trust commits to monitor these once implemented.” Source location Response from East Lancashire NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Test and develop risk-based fluid monitoring, including patient and family recording of fluid intake for inclusion in fluid balance charts.
Verbatim wording from the response “The Trust acknowledges that fluid monitoring is a recognised national challenge across the NHS. We are committed to addressing this issue locally and have implemented, and continue to develop, measures aimed at improving the accuracy and consistency of fluid balance monitoring within our services.” Source location Response from East Lancashire NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine contact with the original surgical department after readmission is not considered necessary where the presenting problem appears unrelated to previous surgery.
Verbatim wording from the response “The third area of concern is that there is currently no process for patient’s who present to the Emergency Department following recent surgery to be seen by the original treating department. This is not amenable to a simple procedure – a referral in the context of a problem unrelated to the surgery, where the surgical team may not have expertise related to that condition, would be both futile and add complexity. In this case the initial presentation did not indicate any link with the previous procedure during triage.” Source location Response from East Lancashire NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concern that unwitnessed seizure activity is not considered in Emergency Department assessment does not reflect current or historic practice.
Verbatim wording from the response “With respect to point 2, this concern appears to have arisen from a miscommunication of the evidence provided and reflects neither current nor historic practice within the Emergency Department. Having contacted the consultant who was giving evidence, the point they were trying to convey was that a history of seizures would not warrant immediate escalation to a doctor (either from triage or subsequently). An actively seizing patient would represent a potential medical emergency, or - were it to occur in the department - a potential deterioration in a patient’s condition and that this therefore would be immediately escalated when reported from any source.” Source location Response from East Lancashire NHS Trust
Open published response
Concerns raised 5 Lack of ultrasound teaching for consultants unable to use ultrasound View source Use of inappropriate research providing false reassurance about suprapubic catheter risks in patients with lower abdominal surgery View source Failure to ensure ancillary prophylactic measures for high-risk patients allocated to Core Lists View source Failure to introduce a recommended standard operating procedure View source Use of suboptimal pre-insertion CT scanning instead of ultrasound for suprapubic catheter insertion 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
Antony Waring · 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
Antony Waring died on 24 June 2020 after a suprapubic catheter insertion perforated two loops of small bowel, leading to peritonitis, intensive care admission and subsequent death. The concerns included delays in introducing a standard operating procedure, the proposed use of CT scanning rather than ultrasound, inadequate ultrasound training, chance-based allocation of high-risk patients, and inappropriate research about complication risks.
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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ultrasound teaching for consultants unable to use ultrasound
Wider context from the report “(3) in the four years since Antony Waring's death, the Trust has not provided a single ultrasound teaching session provided by the Trust to any consultant who is not capable of using ultrasound .
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Use of inappropriate research providing false reassurance about suprapubic catheter risks in patients with lower abdominal surgery
Wider context from the report “(5) The expert evidence at the inquest was that the research provided on the risk of complications after insertion of a suprapubic catheter into patients with lower abdominal surgery is inappropriate the patient such as Antony Waring and provides false reassurance as to the level of risk posed to these patients .
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure ancillary prophylactic measures for high-risk patients allocated to Core Lists
Wider context from the report “(4) the allocation of high-risk patients to Core Lists where a specific ancillary prophylactic measure such as ultrasound is left to either chance or to an administrator ;
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to introduce a recommended standard operating procedure
Wider context from the report “(1) the Trust made no progress on the introduction of an SOP recommended in the internal review for almost 4 years . A draft SOP had been proposed in the week leading up to the inquest.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Use of suboptimal pre-insertion CT scanning instead of ultrasound for suprapubic catheter insertion
Wider context from the report “(2) The expert evidence at the inquest was that the Trust's proposed action plan using CT scanning at an unspecified time before a suprapubic catheter insertion was sub optimal and inferior to ultrasound as bowel may move between the date of the CT scan and the catheter insertion ;
” 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 Schedule complex suprapubic catheter insertions as joint theatre procedures with a responsible Consultant Urologist and an expert Consultant Radiologist with ultrasound equipment available.
Verbatim wording from the response “With regards to the concern regarding ultrasound scanning I can confirm that under the new SOP complex SPC insertions are now listed as a scheduled joint procedure with a Consultant Urological Surgeon and Consultant Radiologist in the theatre suite at Royal Blackburn Hospital. This will ensure the availability and presence of a Consultant Radiologist (with expertise in ultrasound scanning) and the ultrasound scanner itself.” Source location Response ELHT
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 theatre lists weekly, confirm patient suitability before surgery, and use embedded pre-list checks and post-list debriefs to identify equipment needs and learning.
Verbatim wording from the response “I can confirm that weekly meetings are scheduled to review each individual theatre list and these are attended and led by the Trust’s Clinical Director for Urology. At each weekly meeting the individual theatre list for the next two weeks is reviewed, looking at each individual patient case and ensuring that these are suitable.” Source location Response ELHT
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 monitoring and escalation arrangements to assure compliance with the complex suprapubic catheter SOP.
Verbatim wording from the response “As an organisation we constantly strive to improve patient safety and I can confirm these changes have been confirmed by both the Urology and Radiology Departments. In order to ensure the SOP is fully embedded, an assurance process is now in place for monitoring and escalation, with regular audits being introduced and associated assurance reporting.” Source location Response ELHT
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 Approve, ratify and embed a safety SOP for complex suprapubic catheter insertions after previous abdominal or bladder surgery.
Verbatim wording from the response “I am pleased to confirm that the Trust’s SOP for ‘Minimising the risks of supra-pubic catheter insertion in complex cases of patients who have had previous abdominal or bladder surgery’ has now been approved and ratified following the inquest hearing.” Source location Response ELHT
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 Introduce regular audits and associated assurance reporting for compliance with the complex suprapubic catheter SOP.
Verbatim wording from the response “As an organisation we constantly strive to improve patient safety and I can confirm these changes have been confirmed by both the Urology and Radiology Departments. In order to ensure the SOP is fully embedded, an assurance process is now in place for monitoring and escalation, with regular audits being introduced and associated assurance reporting.” Source location Response ELHT
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 not practically feasible to train Urology Consultants to the expertise required for rare, complex cases; Consultant Radiologists therefore provide ultrasound.
Verbatim wording from the response “I can confirm that Suprapubic Catheter placement is only performed by clinicians who are trained and confident to perform that procedure.” Source location Response ELHT
Open published response
Concerns raised 17 Failure to expedite emergency MRI scanning and document escalation attempts View source Failure by treating clinicians to recognise and record activation of the septic shock pathway View source Independent operation of adverse-incident review and Legal Services departments View source Failure to obtain family views and concerns during the adverse-death review View source Inappropriate and undocumented prioritisation of urgent MRI scans View source Incomplete investigation of suspected high cervical-spine infection View source Delays in completing adverse-death review reports View source Radiology scan prioritisation dependent on personal clinician attendance or discussion rather than clinical need View source Failure to identify the responsible specialty and document its management in medical records View source Failure to perform the required contrast MRI scan initially View source Ineffectual detection of adverse outcomes after tertiary-centre transfer and subsequent death View source Failure to expedite scanning or contact tertiary neurosurgical services after specialist input View source Insufficient senior clinical oversight of review conclusions View source Factual inaccuracies in adverse-incident review summaries View source Inappropriate allocation of cases to structured judgement review View source Insufficient MRI scanner capacity for urgent scans View source Failure to evaluate whether MRI capacity changes improve urgent scan times View source See 14 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
Mr Frank Charles Medley · 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 Frank Charles Medley presented with acute weakness in all four limbs, but an MRI scan that was considered urgent was delayed for four working days. He underwent surgery for multiple paraspinal abscesses and died on 14 July 2019. The principal concerns included delays and inadequate prioritisation of imaging, deficiencies in the Trust’s adverse incident review, and shortcomings in systems for detecting adverse outcomes and coordinating relevant departments.
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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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to expedite emergency MRI scanning and document escalation attempts
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan . There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan ;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by treating clinicians to recognise and record activation of the septic shock pathway
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest ;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Independent operation of adverse-incident review and Legal Services departments
Wider context from the report “(3) The Department undertaking reviews of adverse incidents appears to operate independently from the Legal Services Department
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain family views and concerns during the adverse-death review
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest .
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate and undocumented prioritisation of urgent MRI scans
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category . There is no documentation as to any rationale for the priority allocation ;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete investigation of suspected high cervical-spine infection
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG ;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in completing adverse-death review reports
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance ;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Radiology scan prioritisation dependent on personal clinician attendance or discussion rather than clinical need
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need ;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the responsible specialty and document its management in medical records
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform the required contrast MRI scan initially
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day .
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffectual detection of adverse outcomes after tertiary-centre transfer and subsequent death
Wider context from the report “(1) The Trust has an ineffectual system to detect adverse outcomes where the patient is transferred to a tertiary centre for treatment and subsequently dies ;
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to expedite scanning or contact tertiary neurosurgical services after specialist input
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services ;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient senior clinical oversight of review conclusions
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn .
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Factual inaccuracies in adverse-incident review summaries
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading ;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate allocation of cases to structured judgement review
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review ;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient MRI scanner capacity for urgent scans
Wider context from the report “(4) The delay in obtaining the scan was partly attributed to a lack of MRI scanner capacity . At the inquest the Trust could only provide conjecture as to whether or not alterations to scan capacity had made any difference to the time taken to obtain urgent scans.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to evaluate whether MRI capacity changes improve urgent scan times
Wider context from the report “(4) The delay in obtaining the scan was partly attributed to a lack of MRI scanner capacity. At the inquest the Trust could only provide conjecture as to whether or not alterations to scan capacity had made any difference to the time taken to obtain urgent scans .
” 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 Develop and validate a traffic-light system showing radiology diagnostic waits to support escalation of urgent imaging.
Verbatim wording from the response “The Internal Professional Standards (IPS) have been revised by the Radiology Directorate to support the requirements for imaging in this cohort of patients. The compliance with the standards are monitored weekly at the Radiology Performance Meeting. Phase two of the Power BI dashboard development is to include the IPS for in-patient turnaround times. We are also working on a traffic light system which will demonstrate, at a glance, the average waits for radiology diagnostics supporting the need to expedite urgent imaging. The first draft of the traffic light system is now "live" on the radiology intranet site and is being validated prior to display in a more prominent area of the Trust intranet.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 weekly Executive review of divisional investigations before SIRI Panel submission.
Verbatim wording from the response “A weekly Executive review of Divisional investigations due at SIRI Panel has been introduced from 21 April to monitor the quality of reports prior to submission. This aims to ensure that the quality of the investigation may be identified earlier and at a senior enough level to require any further improvements to be made without delaying the process or submission to your court. A pro forma for Serious Incident investigations, with a front sheet for sign off each stage, has been developed in line with the National Patient Safety Strategy and PSIRF requirements; which prompts investigators to clearly link the problems, learning and recommendations to individual actions that are focused on preventing the same incident reoccurring. I understand a pilot version of this proforma was received favourably by one of your team at an inquest last week.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standard operating procedure defining navigator functions and referrer actions for radiology access and efficiency.
Verbatim wording from the response “Radiology in-patient Co-ordinator/Navigator role was established in November 2019. This role has supported improved patient flow and communication between referring clinical teams and the radiology team. Cover is provided 52 weeks of the year by the Radiology Administrative function. A Standard Operating Procedure describing the functions of this role and the actions required by referrers to improve access and efficiency in radiology is being developed to support this function. Communications have been clarified to advise on the most appropriate manner for teams to access the In-patient Navigator. This is the route that teams will use to find out when a scan is planned and also to expedite imaging which has not yet been planned.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 Operate two new MRI systems at Burnley and progress replacement and upgrading of the oldest Blackburn MRI assets.
Verbatim wording from the response “In October 2020, ELHT commissioned two new Magnetic Resonance Imaging (MRI) systems on the Burnley General Teaching Hospital site. These scanners were replacement assets identified as part of the government initiative which aimed to replace all MRI systems over 10 years old. The initial intention was to replace the Philips MRI system at Burnley and the Trust owned asset at RBH. However, due to” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a funded cohort of investigators and family liaison officers with allocated time, training and administrative support.
Verbatim wording from the response “A full review and update of investigation process has been completed, in line with Patient Safety Incident Response Framework. Funding has been agreed in support of a proposal to develop a cohort of investigators and family liaison officers with allocated time, specific training and administrative resource to enable timely and thorough investigations. This team will report to the Assistant Director of Safety and Risk and work in partnership with the legal team to coordinate investigations and learning on behalf of the trust.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 Operate a year-round radiology inpatient coordinator or navigator function to improve referral communication, patient flow and scan escalation.
Verbatim wording from the response “Radiology in-patient Co-ordinator/Navigator role was established in November 2019. This role has supported improved patient flow and communication between referring clinical teams and the radiology team. Cover is provided 52 weeks of the year by the Radiology Administrative function. A Standard Operating Procedure describing the functions of this role and the actions required by referrers to improve access and efficiency in radiology is being developed to support this function. Communications have been clarified to advise on the most appropriate manner for teams to access the In-patient Navigator. This is the route that teams will use to find out when a scan is planned and also to expedite imaging which has not yet been planned.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 inpatient radiology priorities at vetting stage and align time-based priorities with NICE guidance where applicable.
Verbatim wording from the response “We are currently also reviewing the In-patient priorities applied at vetting stage by Radiology. It is anticipated that these will be time-based allowing a better understanding of the priority applied at vetting; aligned to NICE guidance for urgent imaging where stated. This will allow pressures within the system to be escalated so that clinical decisions can be made on how best to proceed.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 review and update of the serious-incident investigation process in line with the Patient Safety Incident Response Framework.
Verbatim wording from the response “A full review and update of investigation process has been completed, in line with Patient Safety Incident Response Framework. Funding has been agreed in support of a proposal to develop a cohort of investigators and family liaison officers with allocated time, specific training and administrative resource to enable timely and thorough investigations. This team will report to the Assistant Director of Safety and Risk and work in partnership with the legal team to coordinate investigations and learning on behalf of the trust.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and use a Serious Incident investigation pro forma with staged sign-off and links between problems, learning and preventive actions.
Verbatim wording from the response “A weekly Executive review of Divisional investigations due at SIRI Panel has been introduced from 21 April to monitor the quality of reports prior to submission. This aims to ensure that the quality of the investigation may be identified earlier and at a senior enough level to require any further improvements to be made without delaying the process or submission to your court. A pro forma for Serious Incident investigations, with a front sheet for sign off each stage, has been developed in line with the National Patient Safety Strategy and PSIRF requirements; which prompts investigators to clearly link the problems, learning and recommendations to individual actions that are focused on preventing the same incident reoccurring. I understand a pilot version of this proforma was received favourably by one of your team at an inquest last week.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the radiology inpatient dashboard to wards and clinical services.
Verbatim wording from the response “The Radiology in patient dashboard has been developed using our business intelligence system and is currently used in key areas of the Trust. Roll out of the dashboard is progressing. The next steps are to demonstrate and share access to the dashboard at the Nursing & Midwifery Forum, Foundation Teaching and Clinical Leadership to accelerate roll out to the wards and clinical services.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 Hold twice-weekly clinico-radiological meetings to discuss difficult cases and support imaging decisions without requiring personal attendance.
Verbatim wording from the response “Clinico-radiological meetings were established in November 2020 and now occur twice weekly on Monday and Friday on AMU. It is intended that when possible, a third meeting will be provided on a Wednesday to provide better support through the working week. This development allows a forum in which difficult cases can be discussed and advice and guidance provided on the optimum imaging technique and/or interpretation of unusual report findings and has been a significant success; building improved relationships and communication between clinical teams on AMU and the radiology directorate. This meeting explicitly addresses the human factors highlighted in this case; ensuring that patient management is equitable regardless of the staff on duty and that clinical discussions can be held without personal attendance.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 Revise radiology Internal Professional Standards and monitor compliance weekly against imaging requirements.
Verbatim wording from the response “The Internal Professional Standards (IPS) have been revised by the Radiology Directorate to support the requirements for imaging in this cohort of patients. The compliance with the standards are monitored weekly at the Radiology Performance Meeting. Phase two of the Power BI dashboard development is to include the IPS for in-patient turnaround times. We are also working on a traffic light system which will demonstrate, at a glance, the average waits for radiology diagnostics supporting the need to expedite urgent imaging. The first draft of the traffic light system is now "live" on the radiology intranet site and is being validated prior to display in a more prominent area of the Trust intranet.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a weekly complex-case coordination meeting integrating legal services and complaints, coordinating investigations and early family liaison.
Verbatim wording from the response “A weekly complex case coordination meeting has been introduced to enable early coordination with legal services and complaints team, to agree appropriate routes for investigation and ensure all families concerns are understood. This has enabled a full review of case currently listed for inquest and any potential delays or concerns regarding linked investigation processes. This complex case group coordinates all cases that cross divisions, are listed for an inquest, have an ongoing investigation of any kind (eg complaint/SJR/LeDeR) and ensures families are contacted by an allocated family liaison officer at as early a stage as possible.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 senior core group to oversee action-plan implementation and monitor embedding into Trust processes.
Verbatim wording from the response “A core group has been established to oversee the implementation of this action plan led by the Associate Director of Quality and Safety, the Deputy Medical Director and Director of Nursing to ensure senior oversight of the issues raised. Please be assured that this group will continue to meet until all actions have been embedded as business as usual into Trust processes with clear reporting and monitoring processes in place.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 Regional Medical Examiner group is to consider establishing a cross-hospital feedback mechanism for detecting deaths after patient transfers.
Verbatim wording from the response “achieving this when asked. Recognising the focus and role of the Medical Examiners, across all Trusts; our Lead Medical Examiner has asked the Regional Team to consider whether these roles could support with this issue. We await a response.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 Systematic follow-up of transferred patients who later die is difficult because the Trust depends on timely notification by other organisations.
Verbatim wording from the response “You raised a concern re the lack of systems to follow up patients who once transferred go on to deteriorate in other Trusts. It has proved difficult to achieve this from a systems perspective. Achieving this is heavily reliant on the Trust being informed of a patient having unfortunately died, in a timely manner. Mr Medley’s case has clearly demonstrated the impact of the absence of this system, but no Trust we have spoken to has been able to describe a standardised systematic approach to” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 MRI scan without contrast was considered appropriate because the clinical question was adequately answered and additional contrast had limited diagnostic utility.
Verbatim wording from the response “The MRI scan in question was vetted on 2nd July 2019 by a senior Consultant Radiologist and CRIS (Radiology Information System) records demonstrate that it was felt that the clinical question posed by the clinical team could be adequately answered by an MRI scan without the administration of contrast media. The referral was re-vetted the next day (3rd July 2019) by a second Consultant Radiologist who also agreed that contrast media was not required.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
Concerns raised 9 Inadequacy of the action plan for reducing delays in NG tube insertion and decompression View source Failure to check medical records completed by junior doctors View source Lack of audit of the effectiveness of safety measures View source Failure of the serious incident investigation to identify why NG tube placement failures were not escalated or referred back to requesting teams View source Failure of nursing escalation when an NG tube cannot be sited and clinical review has not occurred View source Failure to identify and document the staff member, records, and actions relevant to an arterial blood gas during the investigation View source Failure to ensure factual accuracy and evidential support for reported EWS escalation View source Lack of clear allocation of overall clinical responsibility for patients remaining in the Accident and Emergency Department View source Failure to complete or appropriately refer mandated clinical reviews triggered by EWS scores 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
Gillian McKinlay · 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
Gillian McKinlay, aged 68, was admitted to Royal Blackburn Hospital on 23 April 2018 with a provisional diagnosis of small bowel obstruction. A nasogastric tube requested by clinicians was not sited before her death four hours later, and the Coroner considered this contributed to the death. Concerns included unclear responsibility for patients in the Accident and Emergency Department, failure to undertake or escalate a clinically indicated review, and inadequacies in the Trust's investigation and subsequent measures.
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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the action plan for reducing delays in NG tube insertion and decompression
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate ;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check medical records completed by junior doctors
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked ;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of the effectiveness of safety measures
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect .
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the serious incident investigation to identify why NG tube placement failures were not escalated or referred back to requesting teams
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing escalation when an NG tube cannot be sited and clinical review has not occurred
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy .
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and document the staff member, records, and actions relevant to an arterial blood gas during the investigation
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken ;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure factual accuracy and evidential support for reported EWS escalation
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect ;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear allocation of overall clinical responsibility for patients remaining in the Accident and Emergency Department
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care .
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or appropriately refer mandated clinical reviews triggered by EWS scores
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams .
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” Open source report
Concerns raised 3 Failure to supervise patients in the toilet unless a fall has occurred View source Difficulties in transferring and accessing radiology images and reports between hospitals View source Failure of radiology services to carry out Judet X-rays specifically requested by orthopaedic specialists 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
Patrick Clifford · 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
Patrick Clifford fell in a hospital toilet after fainting on 19 March 2016 and suffered a fractured acetabulum. His condition deteriorated, and he developed pneumonia due to immobility and heart failure before dying on 18 September 2016. The principal concerns were inadequate understanding of toilet supervision, difficulties transferring radiology images between hospitals, and refusal to undertake requested Judet X-rays, causing delays to treatment.
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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise patients in the toilet unless a fall has occurred
Wider context from the report “1. The evidence from the nursing staff that a patient would not be supervised within the toilet unless there had been a fall on the ward . It was not clear whether this was a general understanding by nursing staff or a specific policy . I am concerned that future falls (and therefore deaths) will occur unless action is taken to address this policy/understanding.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulties in transferring and accessing radiology images and reports between hospitals
Wider context from the report “2. The evidence from the clinicians was that there were sometimes difficulties in transferring images to other hospitals . In this case there appeared to be misunderstandings as to whether or not Wrightington could access radiology images/reports through the Royal Blackburn Hospital PACS system and vice-versa . In the present case this caused delays in the commencement of necessary physiotherapy treatment and I am concerned that future delays could similarly delay treatment and risk future deaths as a result.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of radiology services to carry out Judet X-rays specifically requested by orthopaedic specialists
Wider context from the report “3. During the course of evidence it became apparent that the Radiology department at the Royal Blackburn Hospital had refused to carry out Judet X-rays as specifically requested by the orthopaedic specialists at Wrightington . This caused delays in commencing partial weight bearing physiotherapy in Mr Clifford’s case. I am concerned that future delays could similarly delay treatment and risk future deaths as a result.
” Open source report
Concerns raised 3 Failure to report a visible hip fracture on an x-ray report View source Failure to carry out requested physiotherapy or occupational therapy review before discharge View source Failure to sign and date handwritten clinical notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alfred Grimshaw · 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
Alfred Grimshaw had an unwitnessed fall at a residential care home on 26 May 2016, was admitted to hospital, and was discharged before being readmitted when a fractured hip was identified. He underwent surgery and died from bronchopneumonia on 6 June 2016. Concerns included the failure to obtain a hip X-ray after the fall and inability to mobilise, failure to report a hip fracture visible on an abdominal X-ray, and lack of evidence that requested physiotherapy or occupational therapy reviews occurred before discharge.
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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report a visible hip fracture on an x-ray report
Wider context from the report “1. On being assessed in the emergency department on the 26th May, despite the history of an unwitnessed fall and the fact that he was 93 years of age and had been subsequently unable to mobilise so x-ray was carried out in order to rule out the possibility of a fracture to his hip.
2. On the 27th May 2016 an x-ray of the abdomen was requested to rule out a sub-acute intestinal obstruction. Although that was an x-ray of the abdomen it covered part of the right hip, which disclosed a significant displaced fracture through the right lesser trochanter that was visible on the lower limit of the film. Despite the fracture being disclosed on the x-ray, the report made no reference to it.
3. On the 27th May a request was made for physio and O T review which was clearly documented, there was however no evidence that physio or O T was carried out prior to discharge.
4. On the discharge summary that was printed on the 28th May 2016 at 16:21 is a handwritten note “Patient off his legs. Pain ++ right hip and during movement. Physio advises x-ray to exclude hip fracture prior to any physiotherapy.” That handwritten note is not signed or dated.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out requested physiotherapy or occupational therapy review before discharge
Wider context from the report “1. On being assessed in the emergency department on the 26th May, despite the history of an unwitnessed fall and the fact that he was 93 years of age and had been subsequently unable to mobilise so x-ray was carried out in order to rule out the possibility of a fracture to his hip.
2. On the 27th May 2016 an x-ray of the abdomen was requested to rule out a sub-acute intestinal obstruction. Although that was an x-ray of the abdomen it covered part of the right hip, which disclosed a significant displaced fracture through the right lesser trochanter that was visible on the lower limit of the film. Despite the fracture being disclosed on the x-ray, the report made no reference to it.
3. On the 27th May a request was made for physio and O T review which was clearly documented, there was however no evidence that physio or O T was carried out prior to discharge.
4. On the discharge summary that was printed on the 28th May 2016 at 16:21 is a handwritten note “Patient off his legs. Pain ++ right hip and during movement. Physio advises x-ray to exclude hip fracture prior to any physiotherapy.” That handwritten note is not signed or dated.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to sign and date handwritten clinical notes
Wider context from the report “1. On being assessed in the emergency department on the 26th May, despite the history of an unwitnessed fall and the fact that he was 93 years of age and had been subsequently unable to mobilise so x-ray was carried out in order to rule out the possibility of a fracture to his hip.
2. On the 27th May 2016 an x-ray of the abdomen was requested to rule out a sub-acute intestinal obstruction. Although that was an x-ray of the abdomen it covered part of the right hip, which disclosed a significant displaced fracture through the right lesser trochanter that was visible on the lower limit of the film. Despite the fracture being disclosed on the x-ray, the report made no reference to it.
3. On the 27th May a request was made for physio and O T review which was clearly documented, there was however no evidence that physio or O T was carried out prior to discharge.
4. On the discharge summary that was printed on the 28th May 2016 at 16:21 is a handwritten note “Patient off his legs. Pain ++ right hip and during movement. Physio advises x-ray to exclude hip fracture prior to any physiotherapy.” That handwritten note is not signed or dated.
” 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 Put specific measures in place to reduce the risk of further radiology reporting errors.
Verbatim wording from the response “2. The x-ray report of 27th May (abdominal x-ray to exclude intestinal obstruction) failed to report the evident right hip fracture. The Radiologist who undertook this report is currently under restricted practice, and subject to a clinical review. I am unable to comment further on this matter, but specific measures have been put in place to ensure that the risk of further errors is reduced.” Source location 2016-0387-Response-by-East-Lancasshire-Hospitals-NHS-Trust
Open published response
Concerns raised 4 Failure to re-assess venous thromboembolism risk 24 hours after admission View source Unavailability of electronic prescribing for drugs prescribed in the Accident & Emergency Department View source Failure to prescribe pharmacological thromboprophylaxis for patients at high risk of venous thromboembolism without contraindications View source Failure to apply mechanical thromboprophylaxis when indicated 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
Karen Ravenscroft · 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
Karen Ravenscroft fell at home on 11 March 2016 and fractured her left arm and leg. She was assessed as being at high risk of venous thromboembolism but was not prescribed appropriate prophylaxis, subsequently developed a deep vein thrombosis, and died from a fatal pulmonary embolus. Concerns included the absence of thromboprophylaxis, failure to reassess VTE risk or provide mechanical prophylaxis, and limitations in electronically prescribing drugs from the Accident & Emergency Department.
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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to re-assess venous thromboembolism risk 24 hours after admission
Wider context from the report “2. Despite Trust VTE Guidelines recommending re-assessment of VTE risk at 24 hours after admission, no further risk assessment took place nor was there application of mechanical thromboprophylaxis like Ted Stocking or Flowtron Pump.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of electronic prescribing for drugs prescribed in the Accident & Emergency Department
Wider context from the report “3. Evidence revealed that drugs prescribed in the Accident & Emergency Department could not be done electronically without the doctor going on the ward in order to be able to do that.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe pharmacological thromboprophylaxis for patients at high risk of venous thromboembolism without contraindications
Wider context from the report “1. The initial venous thromboembolism risk assessment done during the admission as per the Trust’s VTE Guidelines stated that Mrs Ravenscroft was at high risk for VTE with no bleeding risk and no contra-indication for pharmacological thromboprophylaxis. Despite that no thromboprophylaxis was prescribed .
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply mechanical thromboprophylaxis when indicated
Wider context from the report “2. Despite Trust VTE Guidelines recommending re-assessment of VTE risk at 24 hours after admission, no further risk assessment took place nor was there application of mechanical thromboprophylaxis like Ted Stocking or Flowtron Pump .
” Open source report
Concerns raised 1 Lack of a mechanism ensuring essential medications are prescribed, dispensed and administered 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
David Aughton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Aughton sustained a severe traumatic brain injury in 1999 that led to epileptic seizures. During a hospital admission for a cystoscopy in December 2015, his anticonvulsant medication was not administered; he subsequently had a grand mal convulsion causing aspiration pneumonia and died on 25 January 2016. The principal concern was that there was no mechanism to ensure essential medications were prescribed, dispensed and administered.
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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism ensuring essential medications are prescribed, dispensed and administered
Wider context from the report “That despite the fact that his regular medications including lamotrigine and sodium valproate were recorded in his medical records, those medications had not been dispensed, leading to a grand mal convulsion it was apparent that there was no mechanism in place to ensure that essential medications were prescribed, dispensed and administered .
” Open source report
Concerns raised 1 Failure of the obstetric VTE prophylaxis and management policy to comply with NICE guidance 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
Euphemia Lumsden Aldred · 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
Euphemia Aldred fell at home, sustained fractures to her left leg and ankle, and was treated in hospital with a plaster cast. After discharge, she was no longer prescribed low molecular weight heparin, developed a deep vein thrombosis and pulmonary embolism, and died; the report identified that the relevant Trust policy did not comply with NICE guidance on venous thrombo-embolism prevention.
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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the obstetric VTE prophylaxis and management policy to comply with NICE guidance
Wider context from the report “The East Lancashire Hospitals Trust Policy Document: Venous Thrombo-Embolism (VTE) (on Obstetric) Part 1 Prophylaxis, Part II Management of VTE V1.4 October 2015 did not comply with the NICE Guidance on Venous Thrombo-embolism in Adults: Reducing the Risk in Hospital: CG92 January 2010 .
” Open source report
Concerns raised 3 Lack of emergency department visibility of referral acceptance and assessment timing View source Failure of the referral process to identify and rectify errors View source Failure of the Mental Health Liaison Team to identify patients believed to be referred and awaiting assessment 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
Jacqueline 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
On 26 January 2015, Jacqueline Williams was taken to Royal Blackburn Hospital and assessed as being at moderate risk of self-harm, but a referral to the Mental Health Liaison Team was not accepted because of a communication breakdown. She subsequently hanged herself in an emergency department cubicle; concerns related to referral errors and systems that did not make missed or unaccepted referrals readily identifiable and rectifiable.
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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of emergency department visibility of referral acceptance and assessment timing
Wider context from the report “That the process of referral to the Mental Health Liaison Team was subject to human error and that the systems in place failed to provide for such mistakes to be easily identified and rectified. In particular there was no opportunity for staff in the emergency department to see confirmation that a referral had been accepted, the time of that referral and the expected time when a mental health assessment would take place . Likewise the Mental Health Liaison Team did not have a process that whereby they were able to identify those patients that the staff in the emergency department believed had been referred and were awaiting assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the referral process to identify and rectify errors
Wider context from the report “That the process of referral to the Mental Health Liaison Team was subject to human error and that the systems in place failed to provide for such mistakes to be easily identified and rectified . In particular there was no opportunity for staff in the emergency department to see confirmation that a referral had been accepted, the time of that referral and the expected time when a mental health assessment would take place. Likewise the Mental Health Liaison Team did not have a process that whereby they were able to identify those patients that the staff in the emergency department believed had been referred and were awaiting assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Mental Health Liaison Team to identify patients believed to be referred and awaiting assessment
Wider context from the report “That the process of referral to the Mental Health Liaison Team was subject to human error and that the systems in place failed to provide for such mistakes to be easily identified and rectified. In particular there was no opportunity for staff in the emergency department to see confirmation that a referral had been accepted, the time of that referral and the expected time when a mental health assessment would take place. Likewise the Mental Health Liaison Team did not have a process that whereby they were able to identify those patients that the staff in the emergency department believed had been referred and were awaiting assessment .
” Open source report
Concerns raised 1 Failure of medical records to sufficiently highlight a previous diagnosis of a potentially life-threatening condition View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jean Helen Hannon · 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
Jean Helen Hannon underwent a laminectomy in 2011 for altered sensations in her hands and subsequently became quadriplegic and developed autonomic dysreflexia. The principal concern was that Royal Blackburn Hospital medical records did not sufficiently highlight this potentially life-threatening condition, and the consultant physician was unaware of the previous diagnosis when she was admitted in December 2014.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of medical records to sufficiently highlight a previous diagnosis of a potentially life-threatening condition
Wider context from the report “That the medical records retained at the Royal Blackburn Hospital failed to sufficiently highlight the previous diagnosis of a condition that is potentially life threatening .
” 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 Pilot daily problem lists to document ongoing clinical concerns during ward rounds and assessments, with evaluation before rollout to other areas.
Verbatim wording from the response “2. ████████ a consultant geriatrician, is piloting the use of daily problem lists as a technique for documenting on-going concerns during ward rounds and daily assessments. This has been used in other hospitals specifically to address the issue of relevant clinical information not being passed on. This is currently in the pilot phase and will be rolled out to other areas after evaluation.” Source location 2015-0458-Response-by-East-Lancashire-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 Provide GP case summaries through EMIS Web in urgent, emergency and planned admission records.
Verbatim wording from the response “1. The Trust now has access to a case summary from the patients GP notes via an electronic system called ‘EMIS web’. This means that a printed summary of the case record is included as part of the patients case notes for every urgent and emergency admission. For planned admissions this information is gathered during the pre-admission processes. These arrangements have now been in place since April 2015.” Source location 2015-0458-Response-by-East-Lancashire-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 The records do not substantiate autonomic dysreflexia; autonomic instability is considered the more accurate diagnosis.
Verbatim wording from the response “It is the belief of ████████ that Jean Hannon did not have autonomic dysreflexia, and that there is no substantiating evidence in the case-note to say that she did.” Source location 2015-0458-Response-by-East-Lancashire-Hospitals-NHS-Trust
Open published response
Concerns raised 4 Lack of a system to ensure consideration of other prescribed medicines when prescribing tramadol View source Failure of prescribers to apply the maximum tramadol dose for people over 75 View source Failure of drug charts to indicate the precise dispensed tramadol dose View source Failure of prescribers to take patient size and frailty into account 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
Kathleen Cornthwaite · 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
Kathleen Cornthwaite, aged 76, was an inpatient at Pendle Community Hospital when her tramadol prescription was increased after a fall causing a rib injury. The inquest concluded that she died of cardiorespiratory failure due to combined tramadol and fluoxetine toxicity. Concerns included the imprecise tramadol dose recorded, failure to account for her age, size and frailty, and failure to consider interactions with other prescribed medicines.
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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to ensure consideration of other prescribed medicines when prescribing tramadol
Wider context from the report “3. There was no system in place such that the doctor would appreciate the fact that in prescribing tramadol he or she ought to have had regard to other medicines being prescribed particularly in this case fluoxetine.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of prescribers to apply the maximum tramadol dose for people over 75
Wider context from the report “2. That the doctor prescribing was not aware of the maximum dose of tramadol for somebody over 75 years of age and failed to take into account her size and frailty.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of drug charts to indicate the precise dispensed tramadol dose
Wider context from the report “1. That the drug chart failed to indicate the precise dose of tramadol dispensed .
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of prescribers to take patient size and frailty into account
Wider context from the report “2. That the doctor prescribing was not aware of the maximum dose of tramadol for somebody over 75 years of age and failed to take into account her size and frailty .
” Open source report
Concerns raised 2 Insufficient resources for a comprehensive speech and language therapy service View source Failure to respond to swallow assessment referrals within two working days 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
Barry Joseph Dillon · 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
Barry Joseph Dillon was detained under the Mental Health Act at Burnley General Hospital and transferred to Royal Blackburn Hospital following seizures, where he suffered aspiration pneumonias and died on 13 November 2013. The report identified insufficient Speech and Language Therapy resources and a delay in responding to his swallow-assessment referral, with patients considered at risk of aspiration pneumonia that may prove fatal.
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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources for a comprehensive speech and language therapy service
Wider context from the report “I received evidence from ████████, a Specialist Speech and Language Therapist, who stated “There are currently insufficient resources to provide a comprehensive SLT service at the Royal Blackburn Hospital . The Royal College of Speech and Language Therapists’ guidelines recommend a two working day response time to referrals for a swallow assessment. This is not achieved by the SLT service at the Royal Blackburn Hospital and there is a risk assessment in place which is currently on the East Lancashire Hospitals Trust Corporate Risk Register with an accompanying business case identifying the resources required to address the shortfall in provision”.
Although Mr Dillon had been referred to the Speech and Language Therapy Service on 17 October 2013, no action was taken until 1 November 2013. I believe that whilst there remain insufficient resources to provide the service at the Royal Blackburn Hospital patients will continue to be at risk of the development of aspiration pneumonia which may prove to be fatal.
” 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 Lancashire Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to swallow assessment referrals within two working days
Wider context from the report “I received evidence from ████████, a Specialist Speech and Language Therapist, who stated “There are currently insufficient resources to provide a comprehensive SLT service at the Royal Blackburn Hospital. The Royal College of Speech and Language Therapists’ guidelines recommend a two working day response time to referrals for a swallow assessment. This is not achieved by the SLT service at the Royal Blackburn Hospital and there is a risk assessment in place which is currently on the East Lancashire Hospitals Trust Corporate Risk Register with an accompanying business case identifying the resources required to address the shortfall in provision”.
Although Mr Dillon had been referred to the Speech and Language Therapy Service on 17 October 2013, no action was taken until 1 November 2013 . I believe that whilst there remain insufficient resources to provide the service at the Royal Blackburn Hospital patients will continue to be at risk of the development of aspiration pneumonia which may prove to be fatal.
” 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