12 Jun 2026 Suzanne FREDERICKS · Prevention of Future Deaths report Essex
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Concerns raised 1 Failure to provide clinicians caring for transplant patients with reliably up-to-date blood test results View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Suzanne FREDERICKS · 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
Suzanne FREDERICKS, who had previously undergone a liver transplant, was admitted to Colchester General Hospital with liver and kidney problems and died there on 4 November 2024 after treatment was unsuccessful. The principal concern was whether clinicians caring for transplant patients in non-specialist hospitals could obtain sufficiently up-to-date blood test results, as delays in processing laboratory results might affect treatment and survival.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clinicians caring for transplant patients with reliably up-to-date blood test results
Wider context from the report “There is a concern as to how clinicians caring for transplant patients in non-specialist hospitals such as Colchester General Hospital can obtain sufficiently up- to- date blood test results . Not having reliably up- to- date results can, with the complexities that such patients present, mean that a patient’s chance of survival is affected. The arrangements for taking, processing and returning sample results in Colchester General Hospital (and for that matter, other hospitals in the UK) may need to be improved .
” 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 Standardise transplant blood-sample routing through a single contact offering daily tacrolimus assays and sample prioritisation on request.
Verbatim wording from the response “The Trust has however taken the decision to standardise the practice and send all blood samples to a single point of contact that has a daily assay for tacrolimus and can prioritise a sample on request.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The renal unit cannot process specialist transplant tests, so samples must be sent elsewhere for processing and results.
Verbatim wording from the response “The Renal Unit at Colchester General Hospital are able to process most blood samples for transplant patients but at present are not able to process specialist tests, such as tacrolimus concentration. Colchester General Hospital therefore have to obtain blood samples for such tests and send them to a transplant centre to process and return results.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
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9 Mar 2026 Terrence FROST · Prevention of Future Deaths report Suffolk
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Concerns raised 2 Failure of GPs to promptly communicate with the Medical Assessment Unit or Accident and Emergency department View source Failure of internal hospital telephone calls to reach the Medical Assessment Unit View source
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AI-generated summary
Terrence FROST · 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
Terrence Frost died at Ipswich Hospital on 17 July 2024 after a sudden collapse and cardiac arrest during a final admission following repeated presentations with abdominal pain, rectal bleeding and concerning blood test results. Postmortem examination identified significant cardiac and vascular disease, and sepsis was considered to have played a factor despite no infection being identified. The principal concerns were difficulties contacting the hospital’s Medical Assessment Unit and Accident and Emergency department, and Terrence’s five-hour wait in Accident and Emergency before being seen.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of GPs to promptly communicate with the Medical Assessment Unit or Accident and Emergency department
Wider context from the report “Evidence was heard that prior to his attendance in the Accident and Emergency department on the 16th July 2024, Terrence had been seen at home by a paramedic from his surgery, who was concerned by Terrence’s presentation and wanted to admit him to hospital. However, Terrence was reluctant so it was agreed that urgent blood tests would be taken in the first instance.
The results of these tests were seen by a GP, and due to the findings (which indicated a possible serious infection or inflammation) the GP called Terrence and told him to go straight to hospital, and whilst enroute she would speak to the Medical Assessment Unit.
In evidence the GP said she then spent 30 minutes on the telephone trying to contact the Medical Assessment Unit as is the required procedure, to discuss Terrence’s admission.
After being unable to contact the Medical Assessment Unit, the GP contacted Terrence, via a family member, and told him that as she could not contact the Medical Assessment Unit he should head to the Accident and Emergency department instead. The GP told Terrence she would pre-alert the Accident and Emergency department to his arrival.
The GP then spent a further period of time telephoning the Accident and Emergency department but again could not get through.
As such upon arrival, a patient who was considered by their GP to be significantly unwell enough to warrant either admission to the Medical Assessment Unit, or that Accident and Emergency should be pre-alerted to their arrival, was unable to speak to either unit prior to the patient’s arrival.
Terrence endured a 5 hour wait in Accident and Emergency before being seen. Although observations taken at the time of his subsequent admission suggest he had not developed sepsis at this stage, I am concerned that the inability of a GP to be able to promptly communicate with either the Medical Assessment Unit or Accident and Emergency department may lead to future deaths in cases where suspected sepsis or other life threatening conditions have been differentially diagnosed, especially if those conditions have progressed further than Terrence’s had at the time of his arrival.
I am further concerned that evidence was heard from a clinician based at the Ipswich Hospital itself, that they too found contacting the Medical Assessment Unit extremely difficult, with internal hospital telephone calls frequently going unanswered.
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of internal hospital telephone calls to reach the Medical Assessment Unit
Wider context from the report “Evidence was heard that prior to his attendance in the Accident and Emergency department on the 16th July 2024, Terrence had been seen at home by a paramedic from his surgery, who was concerned by Terrence’s presentation and wanted to admit him to hospital. However, Terrence was reluctant so it was agreed that urgent blood tests would be taken in the first instance.
The results of these tests were seen by a GP, and due to the findings (which indicated a possible serious infection or inflammation) the GP called Terrence and told him to go straight to hospital, and whilst enroute she would speak to the Medical Assessment Unit.
In evidence the GP said she then spent 30 minutes on the telephone trying to contact the Medical Assessment Unit as is the required procedure, to discuss Terrence’s admission.
After being unable to contact the Medical Assessment Unit, the GP contacted Terrence, via a family member, and told him that as she could not contact the Medical Assessment Unit he should head to the Accident and Emergency department instead. The GP told Terrence she would pre-alert the Accident and Emergency department to his arrival.
The GP then spent a further period of time telephoning the Accident and Emergency department but again could not get through.
As such upon arrival, a patient who was considered by their GP to be significantly unwell enough to warrant either admission to the Medical Assessment Unit, or that Accident and Emergency should be pre-alerted to their arrival, was unable to speak to either unit prior to the patient’s arrival.
Terrence endured a 5 hour wait in Accident and Emergency before being seen. Although observations taken at the time of his subsequent admission suggest he had not developed sepsis at this stage, I am concerned that the inability of a GP to be able to promptly communicate with either the Medical Assessment Unit or Accident and Emergency department may lead to future deaths in cases where suspected sepsis or other life threatening conditions have been differentially diagnosed, especially if those conditions have progressed further than Terrence’s had at the time of his arrival.
I am further concerned that evidence was heard from a clinician based at the Ipswich Hospital itself, that they too found contacting the Medical Assessment Unit extremely difficult , with internal hospital telephone calls frequently going unanswered .
” 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 Reiterate to bleep holders the importance of answering calls promptly during Medicine Divisional staff meetings.
Verbatim wording from the response “GUIDANCE GIVEN TO BLEEP HOLDERS” Source location Response from East Suffolk & North Essex 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 Restrict the Medical Assessment Unit bleep to external calls, increasing capacity for timely responses and reducing call queues.
Verbatim wording from the response “The bleep in the Medical Assessment Unit is now only used for external calls into the departments, increasing the capacity to answer calls in a timely manner and resulting in shorter call waiting queues.” Source location Response from East Suffolk & North Essex 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 Implement secure electronic patient-record messaging to provide an alternative internal communication route for Medical Assessment Unit users.
Verbatim wording from the response “In October 2025, the Trust implemented a new electronic patient record system, Epic. This new electronic patient record system allows internal users to send secure messages to each other on patient records within the system. This has created a new line of communication internally and has reduced the pressure for response from the medical team for the Medical Assessment Unit providing an alternative means of communication for internal users.” Source location Response from East Suffolk & North Essex NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing electronic messaging, bleep arrangements and ambulance pre-alert processes are considered an adequate response to communication concerns.
Verbatim wording from the response “In October 2025, the Trust implemented a new electronic patient record system, Epic. This new electronic patient record system allows internal users to send secure messages to each other on patient records within the system. This has created a new line of communication internally and has reduced the pressure for response from the medical team for the Medical Assessment Unit providing an alternative means of communication for internal users.” Source location Response from East Suffolk & North Essex NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Primary care providers are expected to request ambulance attendance for patients with suspected sepsis or life-threatening conditions requiring hospital conveyance.
Verbatim wording from the response “In circumstances where a patient is deemed to have suspected sepsis or be in a life-threatening condition presenting to a primary care provider, the expected course of action would be for the primary care provider to seek ambulance attendance to convey the patient to hospital. This would result in the ambulance service pre-alerting the Emergency Department of the patient’s attendance, through a designated hot line for ambulance pre-alerts.” Source location Response from East Suffolk & North Essex NHS Trust
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27 Feb 2026 David James FENN · Prevention of Future Deaths report Essex
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Concerns raised 8 Failure to seek an alternative Consultant's opinion View source Failure to challenge a Consultant's view to discharge View source Failure of the multidisciplinary team meeting to discuss the patient's case View source Failure to follow the Sepsis 6 Pathway View source Failure to appropriately recognise signs of sepsis View source Failure to fully impart and understand crucial clinical information View source Failure to seek an early Consultant Review View source Failure to reapproach the Consultant with fuller information View source See 5 more concerns
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AI-generated summary
David James FENN · 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 James FENN was admitted to hospital with suspected sepsis and septic left knee arthritis, after attending several days earlier with similar symptoms and being discharged home. He subsequently developed severe sepsis and multiorgan failure and died on 12 February 2025. The principal concerns were that sepsis was not appropriately recognised on 28 January, the Sepsis 6 pathway was not followed, timely consultant review was not obtained, and relevant clinical discussions and escalation did not occur adequately.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek an alternative Consultant's opinion
Wider context from the report “5) An alternative Consultant's opinion was not sought .
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to challenge a Consultant's view to discharge
Wider context from the report “4) The junior doctor did not feel able to challenge the view of the Consultant to discharge nor did they seek to reapproach them with fuller information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the multidisciplinary team meeting to discuss the patient's case
Wider context from the report “6) The Multi Disciplinary Team meeting the following morning did not discuss Mr Fenn's case when it should have .
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the Sepsis 6 Pathway
Wider context from the report “1) Signs of sepsis where not appropriately recognised and the Sepsis 6 Pathway was not followed .
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately recognise signs of sepsis
Wider context from the report “1) Signs of sepsis where not appropriately recognised and the Sepsis 6 Pathway was not followed.
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully impart and understand crucial clinical information
Wider context from the report “3) The later attempt to seek the Consultant's views was hampered by the use of a mobile phone which had poor signal in the operating theatre and crucial information was not fully imparted/understood .
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek an early Consultant Review
Wider context from the report “2) An early Consultant Review was not sought .
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reapproach the Consultant with fuller information
Wider context from the report “4) The junior doctor did not feel able to challenge the view of the Consultant to discharge nor did they seek to reapproach them with fuller information .
” 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 Enable Epic to auto-populate the next morning trauma list from referrals to reduce manual list-entry errors.
Verbatim wording from the response “KNEE MDT LIST” Source location Response from East Sussex and North Essex NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement Epic as a unified electronic patient record providing real-time access to clinical information and an integrated communication and escalation platform.
Verbatim wording from the response “Since October 2025, the Trust has implemented a new electronic patient record system, Epic. The Trust has consolidated a vast number of separate systems into one sole system that encompasses all the patient notes. This provides unified, one record per patient for all clinical and administrative data. The impact for patients is as follows:” Source location Response from East Sussex and North Essex NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mandatory sepsis identification and action training through Trust induction and ongoing top-up sessions for staff across all wards and levels.
Verbatim wording from the response “The Trust has delivered and continues to deliver sepsis identification and action training for all staff on all wards and at all levels, as per Trust policy. The training is mandatory, forming part of all Trust inductions, with top up training sessions provided whenever there is a need.” Source location Response from East Sussex and North Essex NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed Sepsis 6 prompts, mandatory data fields, treatment-plan completion checks, senior notifications and monthly compliance monitoring within Epic.
Verbatim wording from the response “When a patient’s NEWS score is calculated as being above 2, the treating clinician needs to answer several sets of questions about the patient’s presentation, to determine whether the ‘sepsis 6 bundle’ should be commenced. The bundle should begin within 1 hour of recognition.” Source location Response from East Sussex and North Essex NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement Martha’s Rule, including daily patient check-ins, rapid review access and advertised escalation routes for concerns about deterioration, treatment or discharge planning.
Verbatim wording from the response “In addition to the above, the Trust has implemented ‘Martha’s Rule’, which allows patients, families, carers and staff to request a rapid clinical review if they are concerned about a patient’s deteriorating condition. It covers communication issues and ensures that concerns about medication, investigations, or discharge planning are resolved. The three core elements of the Rule are:” Source location Response from East Sussex and North Essex NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing escalation and communication pathways are considered appropriate, including consultant review, alternative escalation, and waiting where patients remain stable.
Verbatim wording from the response “A clinical governance presentation took place on 13 January 2026, wherein this matter was discussed at length. The Trust is satisfied that the methods of escalation and communications in place are appropriate and that patient safety remains a priority.” Source location Response from East Sussex and North Essex NHS Foundation Trust
Open published response
2 Feb 2026 Janet Sylvia Daniels · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2 Insufficient familiarity among clinical and nursing staff with palliative and end-of-life care policies and guidance View source Failure to communicate and consult effectively with patients and families about end-of-life care decisions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 9
Action
Add the What Matters to Me form to Epic to support personalised care planning and recording of patient priorities.
Stated completedThe respondent said that this action was complete when they made their response on 13 April 2026. View source
Action
Embed ReSPECT documentation in the Epic patient dashboard for access, completion and reference during care planning.
Stated completedThe respondent said that this action was complete when they made their response on 13 April 2026. View source
Action
Provide patients and families with a Last Days of Life leaflet during initial end-of-life-care planning and discussions.
Stated completedThe respondent said that this action was complete when they made their response on 13 April 2026. View source
Action
Complete and distribute a standalone last-days-of-life guide covering recognition of dying, sensitive communication and commencement of the individualised care plan.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026. View source
Action
Deliver advanced communication training for senior nurses and mental capacity and deprivation-of-liberty training for staff.
Stated completedThe respondent said that this action was complete when they made their response on 13 April 2026. View source
Action
Deliver Trust-wide multidisciplinary education on recognising dying, communication, mental capacity assessments and lasting power of attorney.
Stated completedThe respondent said that this action was complete when they made their response on 13 April 2026. View source
Action
Amend palliative care guidance to clarify decision-making authority, commencement of end-of-life care and use of the individualised last-days-of-life care plan.
Stated completedThe respondent said that this action was complete when they made their response on 13 April 2026. View source
Action
Deliver ongoing education on mental capacity, best-interest decisions, communication, ReSPECT, What Matters to Me, escalation and end-of-life documentation.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026. View source
Action
Align end-of-life-care e-learning with updated policy and new last-days-of-life guidance, including Epic processes and communication requirements.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026. View source See 6 more actions
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AI-generated summary
Janet Sylvia Daniels · 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
Janet Sylvia Daniels died at Colchester General Hospital on 6 October 2024 from pulmonary thromboembolism caused by sepsis arising from a Hickman Line infection, against a background of chronic kidney disease and congestive cardiac failure. The report identified failures to communicate the clinical basis for transitioning her to end-of-life care with her and her family, affecting decisions about withdrawing active treatment. It raised a risk that end-of-life care and withdrawal of treatment may be undertaken prematurely when patients and families are not appropriately consulted.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient familiarity among clinical and nursing staff with palliative and end-of-life care policies and guidance
Wider context from the report “The Trust accepts that there was a significant failure on the part of clinical and nursing staff to communicate effectively with Mrs Daniels and her family in respect to critical clinical decision making, and the basis for such clinical decision making, relating to her transition to end of life care, directly impacting their involvement in decision making regarding the withdrawal of treatment, as required by Trust Policy and Guidance.
Evidence from Trust witnesses, including the Langham Ward Manager/Nursing Sister and two Langham Ward Consultant Gastroenterologists indicated that clinical and nursing staff were insufficiently familiar with the principles set out in the Trusts relevant policies and guidance, including the Trust Palliative Care Guidance issued in April 2025, regarding the relevant considerations involved in the transition from palliative care to end of life care .
Taken together, these two features give rise to a risk that patients and family members may not be appropriately consulted with respect to the basis for and timing of end-of-life care and, accordingly, that withdrawal of active treatment may be prematurely undertaken.
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and consult effectively with patients and families about end-of-life care decisions
Wider context from the report “The Trust accepts that there was a significant failure on the part of clinical and nursing staff to communicate effectively with Mrs Daniels and her family in respect to critical clinical decision making, and the basis for such clinical decision making, relating to her transition to end of life care , directly impacting their involvement in decision making regarding the withdrawal of treatment, as required by Trust Policy and Guidance.
Evidence from Trust witnesses, including the Langham Ward Manager/Nursing Sister and two Langham Ward Consultant Gastroenterologists indicated that clinical and nursing staff were insufficiently familiar with the principles set out in the Trusts relevant policies and guidance, including the Trust Palliative Care Guidance issued in April 2025, regarding the relevant considerations involved in the transition from palliative care to end of life care.
Taken together, these two features give rise to a risk that patients and family members may not be appropriately consulted with respect to the basis for and timing of end-of-life care and, accordingly, that withdrawal of active treatment may be prematurely undertaken.
” 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 Add the What Matters to Me form to Epic to support personalised care planning and recording of patient priorities.
Verbatim wording from the response “Additionally, the Trust uses the ‘What matters to me’ (WMTM) approach to patient care conversations. This is an NHS approach which focuses on the understanding patient priorities, values, and needs to guide personalised care and improve wellbeing. WMTM enables patients to document their priorities, using tools like the “About Me: What Matters to Me” form, which captures information about:” Source location 2026-0202 - Response from East Suffolk and North Essex NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed ReSPECT documentation in the Epic patient dashboard for access, completion and reference during care planning.
Verbatim wording from the response “The Trust utilises the NHS ‘ReSPECT’ (Recommend Summary Plan for Emergency Care and Treatment) form. This document is filled out collaboratively by the patient, their family (where appropriate) and a healthcare worker. It details what is important to the patient when it comes to decision making about their care and treatment and is particularly relevant for patients with complex care needs and for people who are nearing the end of their lives. It is” Source location 2026-0202 - Response from East Suffolk and North Essex NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide patients and families with a Last Days of Life leaflet during initial end-of-life-care planning and discussions.
Verbatim wording from the response “Patients and Family members are provided with a copy of the ‘Last Days of Life’ leaflet during the first stage of EOLC planning/discussions. The leaflet explains what relatives can expect when someone is thought to be in the last few days of life, and how hospital staff will support both the patient and those important to them. The leaflet provides the following information:” Source location 2026-0202 - Response from East Suffolk and North Essex NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete and distribute a standalone last-days-of-life guide covering recognition of dying, sensitive communication and commencement of the individualised care plan.
Verbatim wording from the response “A new standalone guide has been drafted specifically for care in the last days of life, focusing on recognising dying, communication (how to have sensitive and honest conversations with patients and their families) and starting the ICPLDL. Terms to be avoided when discussing EOLC with patients and their family have been included. The Trust is aiming for completion and Trust wide distribution in May 2026.” Source location 2026-0202 - Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver advanced communication training for senior nurses and mental capacity and deprivation-of-liberty training for staff.
Verbatim wording from the response “The Trust has delivered and continues to deliver Mental Capacity Act training for staff on all wards and has booked additional Mental Capacity Act seminars at the local university.” Source location 2026-0202 - Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver Trust-wide multidisciplinary education on recognising dying, communication, mental capacity assessments and lasting power of attorney.
Verbatim wording from the response “• The delivering of a presentation at the Trust wide Multidisciplinary Team half day meeting on 19 March 2026, which included recognising dying, communication and Mental Capacity Assessments (MCA) and Lasting Power of Attorney (LPA).” Source location 2026-0202 - Response from East Suffolk and North Essex NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend palliative care guidance to clarify decision-making authority, commencement of end-of-life care and use of the individualised last-days-of-life care plan.
Verbatim wording from the response “ACTIONS IMPLEMENTED” Source location 2026-0202 - Response from East Suffolk and North Essex NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver ongoing education on mental capacity, best-interest decisions, communication, ReSPECT, What Matters to Me, escalation and end-of-life documentation.
Verbatim wording from the response “Communication and Education
The Trust has carried out further education and upskilling on MCA and best interest decision making. The Trust continues to deliver on-going face to face education, e-learning and communication skills (this includes how and when to use the RESPECT forms and WMTM forms). These training sessions have reinforced expectations regarding escalation, documentation, and multidisciplinary communication in EOLC decisions.” Source location 2026-0202 - Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Align end-of-life-care e-learning with updated policy and new last-days-of-life guidance, including Epic processes and communication requirements.
Verbatim wording from the response “The Trust e-learning for EOLC is being aligned with the updated EOLC policy and a new additional ‘Hospital Care in the Last Days of Life Guidance’. This guidance includes Epic (The Trust’s new Electronic Patient Record) processes, clearer wording on ICPLDL and terms to be avoided when discussing EOLC with patients and their family. Again, the Trust is aiming for completion by May 2026.” Source location 2026-0202 - Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
5 Jan 2026 Suzanne Pemberton · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2 Failure to detect and correct inappropriate ward use of generic re-feeding guides View source Lack of out-of-hours specialist dietetic service or cover for patients at CGH View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Suzanne Pemberton · 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
Suzanne Pemberton died at Colchester General Hospital on 16 September 2024 from pneumonia and sepsis arising from an exacerbation of long-standing bronchiectasis, against a background of severe depressive disorder, malnutrition and chronic frailty. The report identified that she had not received a full in-person dietetic assessment before her death despite repeated referrals, and raised concern that the hospital had no specialist dietetic service or cover outside weekday working hours, creating a risk of avoidable future deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to detect and correct inappropriate ward use of generic re-feeding guides
Wider context from the report “Although, in the specific circumstances of this case, the delay in the provision of an in-person dietetic assessment was not a probable causative factor in Suzanne’s death, the written evidence of a Senior Gastro/Surgical Dietician, admitted under Rule 23, stated:
“At present there is no funding in place to provide any dietetic service for weekends or bank holidays. Wards are encouraged and trained to implement the Malnutrition Universal Screening Time ‘MUST’ care plans and utilise enteral feeding starter regimes where appropriate whilst awaiting dietetic input.” (Emphasis added).
The further written and oral evidence of the Dietic Professional Lead confirmed that CGH only provides any form of dietetic in-put during weekday working hours ie between 08.00 hours and 17.00 hours, Monday to Friday (excluding Bank Holidays). The Professional Lead further reconfirmed, in terms, that outside of those hours there is simply no specialist dietetic service or cover of any kind at all for patients at CGH.
In her evidence she told the inquest that whilst there are, to her knowledge, “different arrangements in different Trusts” to deal with the provision of an ‘out of hours’ service, ranging from on-site clinicians to the availability of on-call advice, no such service of any kind is available at CGH (with proposals advanced by the Dietetic Team for a new business case for funding having not been taken forward).
The Professional Lead gave evidence that, in her view, this lack of service was “far from ideal” and further accepted that this will inevitably mean that there will be cases where, as examples, Naso-gastric feeding may not be started as soon as it should be, or that there will occasions when the written generic ‘re-feeding’ guides provided by her Team to the wards may not be appropriately followed (with such failures not being picked up and corrected by her Team ).
She accepted that in such circumstances this could give rise to the risk of (avoidable future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of out-of-hours specialist dietetic service or cover for patients at CGH
Wider context from the report “Although, in the specific circumstances of this case, the delay in the provision of an in-person dietetic assessment was not a probable causative factor in Suzanne’s death, the written evidence of a Senior Gastro/Surgical Dietician, admitted under Rule 23, stated:
“At present there is no funding in place to provide any dietetic service for weekends or bank holidays. Wards are encouraged and trained to implement the Malnutrition Universal Screening Time ‘MUST’ care plans and utilise enteral feeding starter regimes where appropriate whilst awaiting dietetic input.” (Emphasis added).
The further written and oral evidence of the Dietic Professional Lead confirmed that CGH only provides any form of dietetic in-put during weekday working hours ie between 08.00 hours and 17.00 hours, Monday to Friday (excluding Bank Holidays). The Professional Lead further reconfirmed, in terms, that outside of those hours there is simply no specialist dietetic service or cover of any kind at all for patients at CGH.
In her evidence she told the inquest that whilst there are, to her knowledge, “different arrangements in different Trusts” to deal with the provision of an ‘out of hours’ service, ranging from on-site clinicians to the availability of on-call advice, no such service of any kind is available at CGH (with proposals advanced by the Dietetic Team for a new business case for funding having not been taken forward).
The Professional Lead gave evidence that, in her view, this lack of service was “far from ideal” and further accepted that this will inevitably mean that there will be cases where, as examples, Naso-gastric feeding may not be started as soon as it should be, or that there will occasions when the written generic ‘re-feeding’ guides provided by her Team to the wards may not be appropriately followed (with such failures not being picked up and corrected by her Team).
She accepted that in such circumstances this could give rise to the risk of (avoidable future deaths.
” 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 Include dietetic-care-planning adherence monitoring in the 2026/27 audit programme and conduct regular audits for assurance, learning and feedback.
Verbatim wording from the response “The Trust has, through the implementation of a new electronic patient record system, the capability to monitor adherence and compliance with dietetic care planning in real time. This will now make up part of the Trust’s audit programme. This audit has been registered formally within the 2026/27 Audit Programme, which will enable regular audit cycle to give assurance on compliance and learning opportunities and feedback to the Division/Trust on areas of concern.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out a therapeutic review across both sites to align dietetic policies, procedures and practices with current guidance and ensure consistent implementation.
Verbatim wording from the response “A therapeutic review of processes is being carried out across both sites to ensure policies, procedures and practices are in line with current guidance and are implemented in a consistent approach throughout the Trust.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enable real-time monitoring of adherence to dietetic care planning through the new electronic patient record system.
Verbatim wording from the response “The Trust has, through the implementation of a new electronic patient record system, the capability to monitor adherence and compliance with dietetic care planning in real time. This will now make up part of the Trust’s audit programme. This audit has been registered formally within the 2026/27 Audit Programme, which will enable regular audit cycle to give assurance on compliance and learning opportunities and feedback to the Division/Trust on areas of concern.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an out-of-hours escalation process for dietetic support and audit compliance regularly.
Verbatim wording from the response “The dietetics team are also seeking to develop an escalation process for out of hours periods, which will be compliance audited regularly.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a project to ensure relevant ward areas receive consistent, compliant dietetic-care-planning training.
Verbatim wording from the response “To ensure that patients who may need dietetic input outside of the weekday working hours receive the right care, the Trust has undertaken a project to ensure all relevant ward areas receive consistent and compliant training related to dietetic care planning.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Weekday dietetic support, robust care plans and enteral feeding starter regimes are considered sufficient outside weekday working hours.
Verbatim wording from the response “As an Acute Medical Trust, East Suffolk and North Essex NHS Foundation Trust (“ESNEFT”) provide a wide range of services to patients, some of which necessitate 7-day coverage, while others do not mandate a permanent presence within a 7-day period. ESNEFT must manage these competing service needs within the constraints of finite funding availability across all its services.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
25 Sep 2025 Susan Margaret Barrett · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Absence of embedded, dedicated Tissue Viability Nurses and a Tissue Viability Service across Community Hospital Wards View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Margaret Barrett · 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
Susan Margaret Barrett died on 30 July 2024 from sepsis arising from osteomyelitis caused by a Grade 4 sacral pressure ulcer, against a background of dementia. The ulcer deteriorated during and after hospital care, with communication failures contributing to at least a two-month delay in daily nursing care. Concerns were also raised about the absence of embedded Tissue Viability Nurses or a Tissue Viability Service across community hospital wards and the resulting risk to vulnerable patients.
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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of embedded, dedicated Tissue Viability Nurses and a Tissue Viability Service across Community Hospital Wards
Wider context from the report “However, serious concerns were raised in evidence by East Suffolk and North Essex NHS Foundation Trust (ESNEFT) witnesses relating to the impact and consequences of an absence of embedded, dedicated Tissue Viability Nurses (TVNs) and a Tissue Viability Service (TVS) across the two ESNEFT Community Hospital Sites which, together, involve three Wards (including Trinity Ward) with, cumulatively, some 77 patient beds.
The Community Hospital Wards are Nurse Practitioner led and based on a GP model but since 2023 have seen the withdrawal of embedded TVNs or a TVS across all Wards . The evidence from both the Colchester General Hospital Matron and the Community Tissue Viability Lead Nurse confirmed that whilst this has been formally recognised as a ‘risk’ - and attempts at mitigation have been attempted - the steps taken have been inadequate .
In her evidence the Tissue Viability Lead Nurse confirmed that she had raised and escalated her concerns regarding the change in policy and informed the Court that she had felt it necessary to “block” some transfers of vulnerable patients from the Acute Hospital to the Community Hospital, expressly on the basis that the absence of an embedded TVS gave rise to a serious risk of the deterioration of these frail and vulnerable patients’ pressure ulcers to the extent, she confirmed, that such transfers presented a risk of future deaths. Notwithstanding the ‘blocking’ she has been required to resort to, she made reference to an increase in pressure damage in the Community Hospital Wards in a 2025 three month period compared to the same period in 2024 .
” 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 Fund and approve establishment of a substantive 0.6 WTE Band 6 Tissue Viability CNS post.
Verbatim wording from the response “The Medicine and Community Services North East Essex division within the Trust have confirmed funding for 0.6wte Band 6 Tissue Viability CNS as a substantive post.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit a 0.6 WTE Band 6 Tissue Viability CNS to provide tissue viability services across community hospital sites.
Verbatim wording from the response “RECRUITMENT OF ADDITIONAL TVN RESOURCE TO EMBED A TVS ACROSS COMMUNITY HOSPITAL SITES” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
4 Jun 2025 DAVID HEFFER · Prevention of Future Deaths report Essex
View report summary
Concerns raised 4 Failure to maintain legible medical records View source Failure to inform the treating doctor of readmission with a procedure complication View source Lack of complete medical records containing pertinent and relevant information View source Failure to seek treating-doctor advice about potential causes of complications View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
DAVID HEFFER · 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 Heffer died on 13 April 2024 from septicaemia due to acute peritonitis following duodenal and omental perforation after an ERCP performed for obstructive jaundice. He was discharged on the day of the procedure and readmitted the next day in severe pain with biliary sepsis and perforation. Concerns included failure to inform the treating doctor of the readmission and incomplete or illegible medical records.
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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain legible medical records
Wider context from the report “(2) The medical records did not contain all of the pertinent and relevant information and some were illegible causing difficulty in interpretation .
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the treating doctor of readmission with a procedure complication
Wider context from the report “(1) The treating doctor was not informed when Mr Heffer was readmitted with a complication of the ERCP procedure , and his advice was not sought about potential causes of the complication. The treating doctor only found out about the readmission on contact from coroner’s office .
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of complete medical records containing pertinent and relevant information
Wider context from the report “(2) The medical records did not contain all of the pertinent and relevant information and some were illegible causing difficulty in interpretation.
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek treating-doctor advice about potential causes of complications
Wider context from the report “(1) The treating doctor was not informed when Mr Heffer was readmitted with a complication of the ERCP procedure, and his advice was not sought about potential causes of the complication . The treating doctor only found out about the readmission on contact from coroner’s office.
” 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 Reinforce informing procedural endoscopists about ERCP complications through team reminders, handover guidance and clinical education.
Verbatim wording from the response “The Trust acknowledges the need for better communication between clinicians. Reminders will be provided to all general surgical teams, who remain the primary team managing ERCP-related complications, as agreed unanimously at the regional ERCP Clinical Delivery Group—that where feasible, the procedural endoscopist should be informed of any complication arising from an ERCP they performed. The expectation is that a phone call should be made to inform the procedural endoscopist of the readmission. Informing procedural endoscopists of any complication arising from an ERCP they performed will be included in departmental handover guidance and reinforced through clinical education sessions.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the EPIC electronic patient record system with centralised, legible records, mandatory clinical fields, structured endoscopy templates and alerts for required actions.
Verbatim wording from the response “The Trust is in the process of implementing a new electronic patient record system, provided by EPIC, to transition their patient records system to an electronic system, meaning that by October 2025, all ESNEFT patient record keeping will be done electronically.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
30 Dec 2024 Denise Ellen Johnson · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 4 Failure to conduct timely formal ERCP case reviews with endoscopy colleagues View source Failure to provide regular explanations and discussions with NOK/family about ongoing management plans and treatment options for inpatients with serious surgical issues View source Failure to provide timely notification to ERCP practitioners following serious procedure-based complications View source Lack of clarity over named Surgical Consultant cover for surgical inpatients during unexpected leave View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Denise Ellen Johnson · 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
Denise Ellen Johnson was admitted to hospital with abdominal pain and jaundice, underwent ERCP with stent insertion, and subsequently developed severe acute necrotising pancreatitis. Despite intensive supportive care, drainage, antibiotics and other treatment, she died on 24 November 2022; the inquest recorded multi-organ failure, severe E. coli septicaemia, pancreatic necrosis and ischaemic bowel perforation. The principal concerns were delayed notification and formal review of serious ERCP complications, inadequate communication with the next of kin and family about management plans, and unclear consultant cover during unexpected leave, each identified as posing a significant risk to patient safety.
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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct timely formal ERCP case reviews with endoscopy colleagues
Wider context from the report “Not having timely notification to ERCP practitioners following serious procedure-based complications, and timely associated formal ERCP case review with endoscopy colleagues
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide regular explanations and discussions with NOK/family about ongoing management plans and treatment options for inpatients with serious surgical issues
Wider context from the report “Not having regular explanations and discussions with NOK/family by the responsible Consultant concerning ongoing management plans and treatment options for inpatients with serious surgical issues and,
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely notification to ERCP practitioners following serious procedure-based complications
Wider context from the report “Not having timely notification to ERCP practitioners following serious procedure-based complications , and timely associated formal ERCP case review with endoscopy colleagues
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity over named Surgical Consultant cover for surgical inpatients during unexpected leave
Wider context from the report “Lack of clarity over named Surgical Consultant cover with responsibility for surgical inpatients during periods of unexpected leave
” 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 Embed the approved consultant sickness-absence SOP within the surgical division.
Verbatim wording from the response “We will embed this SOP within the surgical division. Learning from both the incident and the new SOP will be used to drive improvement Trust wide.” Source location Response from East Suffolk and North Essex Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind colleagues that the on-call consultant can respond to acute deterioration or concerns when the named consultant is unavailable.
Verbatim wording from the response “I can also provide assurance that there will be a more general reminder to all colleagues of the availability of the on call consultant to respond to acute deterioration/concern should the named consultant be unavailable.” Source location Response from East Suffolk and North Essex Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement allocation of a named consultant to patients to improve access for patients and families discussing treatment plans.
Verbatim wording from the response “The Trust is also implementing changes to ensure a named Consultant is allocated to patients, which will provide greater accessibility for patients and families to discuss treatment plans.” Source location Response from East Suffolk and North Essex Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Approve a cross-site SOP addressing patient cover during unexpected general surgery consultant leave.
Verbatim wording from the response “A cross-site SOP has been drafted and approved since the Inquest entitled “Patient Take Over During Sickness Absence of a General Surgery Consultant” which addresses cover for patients in the circumstance of unexpected consultant leave.” Source location Response from East Suffolk and North Essex Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish three-monthly ERCP multidisciplinary meetings, with serious inpatient complications notified to the endoscopy lead for formal case review.
Verbatim wording from the response “The Trust’s endoscopy unit are now starting 3 monthly ERCP Multi-Disciplinary Team meetings, where all cases and complications will be discussed. Any inpatients who develop severe complications” Source location Response from East Suffolk and North Essex Foundation Trust
Open published response
19 Jun 2024 Chloe HUNT · Prevention of Future Deaths report Essex
View report summary
Concerns raised 10 Failure to document low oxygen saturation and oxygen prescription View source Failure to recognise deteriorating clinical condition View source Delay in recording the first heart rhythm during resuscitation View source Failure to assess the need for anaesthesia when planning repeated foreign-body removal procedures View source Lack of urgency in treating the patient View source Failure to consider the complexities of foreign-body removal when selecting endoscopic or surgical treatment View source Failure to investigate the underlying cause of persistent tachycardia and low blood pressure View source Failure to recognise changing oxygen requirements and heart rate as signs of deterioration View source Failure to factor complex trauma and difficulty being in hospital into treatment planning View source Failure to consider the whole clinical picture alongside NEWS Scores View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Chloe HUNT · 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
Chloe Hunt died in hospital on 15 March 2022 after swallowing pens that caused gastrointestinal obstruction and a fatal cardiac arrhythmia secondary to metabolic derangement. The concerns included insufficient consideration of her trauma-related difficulties in hospital, delays and inadequate planning for removal of the pens, and failure to recognise and respond to her deteriorating clinical condition.
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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document low oxygen saturation and oxygen prescription
Wider context from the report “f. Chloe’s low oxygen saturation level and the prescription of Oxygen was not documented on 14 March .
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deteriorating clinical condition
Wider context from the report “c. There was a lack of urgency in treating Chloe and lack of recognition of her deteriorating clinical condition .
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in recording the first heart rhythm during resuscitation
Wider context from the report “g. From the timing of the recognition of Chloe’s in-hospital cardiac arrest there was approximately 10 minutes before the first heart rhythm was recorded during the resuscitation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess the need for anaesthesia when planning repeated foreign-body removal procedures
Wider context from the report “b. The requirement for reintubation after each pen removal and the difficulty for a patient to tolerate multiple procedures without anaesthetic was not considered for Chloe on referral for removal , or whether this might need to be converted to a procedure under anaesthetic .
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of urgency in treating the patient
Wider context from the report “c. There was a lack of urgency in treating Chloe and lack of recognition of her deteriorating clinical condition.
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the complexities of foreign-body removal when selecting endoscopic or surgical treatment
Wider context from the report “a. Imaging established Chloe had swallowed 3 full-sized pens, 2 free in her stomach and 1 was impacted in her duodenum. There was a lack of consideration of the complexities of removal to guide whether the removal should be endoscopic or surgical. Endoscopy could not be converted into a procedure under anaesthetic in the interventional radiology suite.
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate the underlying cause of persistent tachycardia and low blood pressure
Wider context from the report “d. Chloe was tachycardic throughout her admission with low blood pressure and there was no investigation of the underlying cause in a young otherwise physically healthy woman. NEWS Scores should not replace consideration of the whole clinical picture for a patient.
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise changing oxygen requirements and heart rate as signs of deterioration
Wider context from the report “e. In the hours before Chloe’s death, she required oxygen for the first-time that was administered for approximately 75 minutes and Chloe’s heart rate reduced to normal for several hours for the first time in her admission. This reduction was not sustained, and her heart rated elevated later. These changes were not recognised as signs Chloe was a deteriorating patient.
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to factor complex trauma and difficulty being in hospital into treatment planning
Wider context from the report “a. Chloe explained on 11 March 2022 in Accident & Emergency to the doctor her background of complex trauma and how difficult she found it to be in hospital. This was not factored into a plan for treatment.
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the whole clinical picture alongside NEWS Scores
Wider context from the report “d. Chloe was tachycardic throughout her admission with low blood pressure and there was no investigation of the underlying cause in a young otherwise physically healthy woman. NEWS Scores should not replace consideration of the whole clinical picture for a patient.
” 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 Circulate learning requiring oxygen saturations to be recorded before oxygen administration.
Verbatim wording from the response “The Trust has however acknowledged that the low saturations were not recorded in the notes. This learning point has been circulated to staff members, through the daily ward huddle, reiterating the need for oxygen saturations to be recorded prior to the administration of oxygen.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transition all Trust patient records to the EPIC electronic records system by 2025.
Verbatim wording from the response “The Trust has recently signed a contract with EPIC to transition its patient records system to an electronic system, meaning that by 2025, all ESNEFT patient record keeping will be done electronically.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss the case with ward and governance staff to promote recognition of underlying causes of abnormalities in apparently stable patients.
Verbatim wording from the response “Chloe’s case has been discussed with staff members, through the daily ward huddle and the Two at the Top meeting (outlined below) as well as at the joint governance meeting to promote learning from Chloe’s case and highlight additional actions that can be taken to help establish potential underlying causes for abnormalities in an otherwise seemingly stable patient.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate learning on persistent tachycardia and the need for further investigations to identify its underlying cause.
Verbatim wording from the response “The Trust has however reviewed the case and acknowledge that a further electrocardiogram could have been undertaken during the admission to provide further clinical insight into Chloe’s condition.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct monthly external peer audits of randomly selected ward notes against quality standards to identify and share documentation learning.
Verbatim wording from the response “In addition to the steps above, the ward notes are subject to a clinical audit, which are peer reviewed (excluding Acute Kidney Injury and Sepsis which are done at ward level) from an external team, who visit the ward monthly and carry out a review of a randomly selected 10 patient notes, reviewing these against the quality standards. This enables the ward to obtain an external view on note keeping and promote learning established from outside the ward.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The clinical presentation did not clearly indicate impending acute deterioration from upper gastrointestinal obstruction or grossly abnormal electrolytes.
Verbatim wording from the response “It is noted that on the evening prior to her cardiac arrest, Chloe was still taking her tablets herself with sips of water. Chloe got up to go to the toilet at 3:45am and interacted with the nurses about her cannula/drip stand. While Chloe was asking to pain relief, there is no clear evidence that Chloe had suffered a perforation, nor was the description of Chloe’s presentation and interactions on the evening a sign of a patient who was about to have an event relating to an upper gastrointestinal obstruction and grossly abnormal electrolytes.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Proceeding to endoscopy was clinically indicated and reasonable based on the available information, assessed risks and informed consent.
Verbatim wording from the response “Having reviewed the decision process taken on Monday 14 March 2022, it is noted that the available imaging did not confirm that a pen was impacted, and the clinicians caring for Chloe could only establish that the pen impacted by undertaking an endoscopy. Up to this point, it was the working diagnosis that the pens could all be removed safely under endoscopy.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
4 May 2024 Michael John BURKE · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Inadequate handover arrangements for outstanding falls assessments between shifts View source Inadequate arrangements for highlighting incomplete risk assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael John BURKE · 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
Michael John Burke, who had advanced lung disease and COPD, died on 2 February 2023 after developing pneumonia and sustaining a fractured neck of femur in a fall on a hospital ward. The principal concern was that Ipswich Hospital lacked adequate arrangements for completing, highlighting and handing over falls-risk assessments, leaving the assessment incomplete when he fell.
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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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate handover arrangements for outstanding falls assessments between shifts
Wider context from the report “The Court heard evidence that risk assessments were to be carried out regularly on patients in relation to their falls risk. This is particularly important in circumstances where a patient was being transferred between wards/units within the hospital and where the risk to the patient may change due to the change in environment. Mr. BURKE was such a risk from falling whilst on the ward and therefore arrangements were required to be put in place to manage this risk, informed by a risk assessment. He had been admitted to Ipswich Hospital on 26th January 2023 following an unimpressed fall at rehabilitation centre where he had been discharged to from Ipswich Hospital the previous day; 25th January 2023.
Mr. BURKE was moved to a new ward on the 30th January 2023 following his admission, assessment and initial treatment. He was not risk assessed when transferred to the ward and the outstanding task to carry out the risk assessment had not been completed by the end of the shift during which he had been transferred onto the ward. This requirement was not handed over to the on-coming shift and a falls risk assessment had not been completed at the time Mr. BURKE sustained a fall on the ward.
I am concerned that Ipswich Hospital has inadequate arrangements in place to both highlight circumstances where the requirement for risk assessments have not been completed and in the arrangements for the handover of tasks (particularly falls assessments) between shifts.
I am further concerned that the failure to have adequate arrangements in place to address this raises a risk of future deaths which I am under a duty to bring to your attention.
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate arrangements for highlighting incomplete risk assessments
Wider context from the report “The Court heard evidence that risk assessments were to be carried out regularly on patients in relation to their falls risk. This is particularly important in circumstances where a patient was being transferred between wards/units within the hospital and where the risk to the patient may change due to the change in environment. Mr. BURKE was such a risk from falling whilst on the ward and therefore arrangements were required to be put in place to manage this risk, informed by a risk assessment. He had been admitted to Ipswich Hospital on 26th January 2023 following an unimpressed fall at rehabilitation centre where he had been discharged to from Ipswich Hospital the previous day; 25th January 2023.
Mr. BURKE was moved to a new ward on the 30th January 2023 following his admission, assessment and initial treatment. He was not risk assessed when transferred to the ward and the outstanding task to carry out the risk assessment had not been completed by the end of the shift during which he had been transferred onto the ward. This requirement was not handed over to the on-coming shift and a falls risk assessment had not been completed at the time Mr. BURKE sustained a fall on the ward.
I am concerned that Ipswich Hospital has inadequate arrangements in place to both highlight circumstances where the requirement for risk assessments have not been completed and in the arrangements for the handover of tasks (particularly falls assessments) between shifts.
I am further concerned that the failure to have adequate arrangements in place to address this raises a risk of future deaths which I am under a duty to bring to your attention.
” 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 Apply a six-hour timeframe for completing falls risk assessments after admission or ward transfer.
Verbatim wording from the response “For this reason East Suffolk and North Essex NHS Foundation Trust sets a 6 hour assessment timeframe, from admission to hospital or change of ward, for the assessment to be carried out, to make patients as safe as can be.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transition patient record keeping to an electronic system across the Trust by 2025.
Verbatim wording from the response “The Trust has recently signed a contract to transition their patient records system to an electronic system, meaning that by 2025, all ESNEFT patient record keeping will be done electronically.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit falls documentation through weekly ward-manager checks and monthly Matron quality audits.
Verbatim wording from the response “As part of the Trust’s accountability framework, patient notes are audited frequently to ensure that they are being completed correctly and to identify any issues with compliance in completing notes.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Falls Prevention Policy to require moving-and-handling assessments and Falls Prevention Integrated Care Pathways within six hours of admission or ward transfer.
Verbatim wording from the response “As part of the ongoing review process of our policies, the Trust has reviewed and updated their Falls Prevention Policy, which provides staff with guidance on the need to complete a moving and handling assessment and Falls Prevention Integrated Care Pathway within 6 hours of a decision to admit or transfer wards. This policy will be signed off at the Patient Safety Group on 18 June 2024.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the Integrated Patient Record with an updated falls risk assessment proforma specifying the six-hour completion requirement.
Verbatim wording from the response “The Trust has also carried out a review of the Integrated Patient Record, which forms an appendix to the Falls Prevention Policy, has been amended and now includes an updated Falls risk assessment proforma, which highlights the need for the assessment to be completed within the 6 hour time period of admission/change of ward.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
Open published response
28 Sep 2020 June Patricia Margaret PARLOUR · Prevention of Future Deaths report Essex
View report summary
Concerns raised 8 Failure to maintain hospital morphine administration guidelines in line with current BNF guidance View source Failure to detect incorrect IV morphine dose guidance in incident-report review View source Incorrect quotation of hospital IV morphine dose guidelines in Serious Incident reports View source Inadequate education on safe morphine doses for newly qualified and locum doctors View source Lack of staff familiarity with national and hospital morphine guidelines View source Drug chart design failing to provide clear titration instructions for one-off IV morphine doses View source Failure to enable nurses to challenge or escalate unsafe morphine prescriptions View source Failure to audit education on safe morphine doses View source See 5 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
June Patricia Margaret PARLOUR · 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
June Parlour was an inpatient with disseminated terminal cancer when she received morphine doses exceeding national and hospital guidelines. Her condition deteriorated, and she later died of opiate toxicity; the overdose significantly hastened her death. Concerns included staff awareness of morphine guidance, inaccurate hospital guidance and incident reporting, education and auditing for doctors, unclear prescribing instructions, and communication and escalation failures between staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain hospital morphine administration guidelines in line with current BNF guidance
Wider context from the report “4) I am concerned that the hospital’s own guidelines regarding morphine administration for acute pain management have not been revised since 2013 and are at odds with the current BNF guidelines (in terms of appropriate doses and patient vulnerability) .
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to detect incorrect IV morphine dose guidance in incident-report review
Wider context from the report “(2) It was concerning that even the hospital’s own Serious Incident report had incorrectly quoted the hospital’s guidelines as to the safe dose of IV morphine and that neither the investigatory team or any of the clinical staff who subsequently read that report had picked up on this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incorrect quotation of hospital IV morphine dose guidelines in Serious Incident reports
Wider context from the report “(2) It was concerning that even the hospital’s own Serious Incident report had incorrectly quoted the hospital’s guidelines as to the safe dose of IV morphine and that neither the investigatory team or any of the clinical staff who subsequently read that report had picked up on this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate education on safe morphine doses for newly qualified and locum doctors
Wider context from the report “(3) I am concerned as to the adequacy of education re safe morphine doses that newly qualified doctors and locum doctors receive , and how this is audited.
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff familiarity with national and hospital morphine guidelines
Wider context from the report “(1) During the course of the hearing it became apparent that staff on the ward (whether doctor or nurse) were not familiar with either the national morphine guidelines (BNF) or indeed those of the hospital . The Court is concerned that such lack of awareness may not be limited to that ward or that hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Drug chart design failing to provide clear titration instructions for one-off IV morphine doses
Wider context from the report “5) I was concerned that this incident arose as a result of a doctor and a nurse failing to understanding each other, and the nurse subsequently feeling that she had no choice but to administer an IV dose that she believed to be dangerous, and in particular that:
a) The drug charts design did not facilitate clear instructions for titration for one-off doses of IV morphine .
b) The nurse did not feel confident enough to challenge the prescription (as she perceived it) effectively or escalate / refer to another doctor.
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to enable nurses to challenge or escalate unsafe morphine prescriptions
Wider context from the report “5) I was concerned that this incident arose as a result of a doctor and a nurse failing to understanding each other, and the nurse subsequently feeling that she had no choice but to administer an IV dose that she believed to be dangerous, and in particular that:
a) The drug charts design did not facilitate clear instructions for titration for one-off doses of IV morphine.
b) The nurse did not feel confident enough to challenge the prescription (as she perceived it) effectively or escalate / refer to another doctor .
” 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 Suffolk and North Essex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to audit education on safe morphine doses
Wider context from the report “(3) I am concerned as to the adequacy of education re safe morphine doses that newly qualified doctors and locum doctors receive, and how this is audited .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish trained investigating officers and a team-based process for patient safety incident investigations.
Verbatim wording from the response “The Trust has been selected as one of the early adopters for the new NHS Patient Safety Incident Response Framework, which commenced on the 2 November 2020. In establishing the new framework ESNEFT has put in place a number of highly trained investigating officers to lead the patient safety incident investigations, utilising relevant clinical experts within the process. Through a team approach to investigations, greater scrutiny of the information and evidence provided will be undertaken and will support a timely response to incidents and the identification of improvements required. The framework aims to ensure investigations are undertaken in a timely manner and with a greater involvement of patients, families and carers.” Source location 2020-0186-Response-from-East-Suffolk-and-North-Essex_Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate and publish the updated Morphine and Naloxone Administration Guidelines for Trust-wide staff access.
Verbatim wording from the response “We have reviewed and updated the ESNEFT Morphine Administration Guideline and the Naloxone Administration Guideline in line with those set out in the British National Formulary (BNF). Both guidelines have been communicated to staff through the Chief Medical Officer’s ‘Doctors Round’ and the guidelines are published on the Trust intranet and on the medications specific application ‘Medusa’ where they are easily accessible by staff in all areas within the Trust.” Source location 2020-0186-Response-from-East-Suffolk-and-North-Essex_Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update junior doctor induction with high-risk medication training and provide additional training for higher-grade doctors in training.
Verbatim wording from the response “To capture Doctors in training, the Medical Directors of Education have engaged and communicated the guidelines, and updated the junior doctor induction programme to ensure this is embedded in practice moving forward.” Source location 2020-0186-Response-from-East-Suffolk-and-North-Essex_Redacted.pdf
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 Roll out the approved Morphine Prescription sticker across inpatient prescription charts and audit its use.
Verbatim wording from the response “Through a QI process we have developed and approved a new Morphine Prescription sticker for use on prescription charts across all inpatient areas. These are currently out to printers, with a planned roll out programme to take place in December 2020. To close the loop on the QI process this will be subject to audit by the Acute Pain Team.” Source location 2020-0186-Response-from-East-Suffolk-and-North-Essex_Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Morphine Administration Competency Framework for inpatient staff administering and monitoring morphine.
Verbatim wording from the response “Further to this we have updated the Morphine Administration Competency Framework for inpatient staff who administer and monitor morphine administration.” Source location 2020-0186-Response-from-East-Suffolk-and-North-Essex_Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update locum and agency staff induction and monitor completion through the Education Team.
Verbatim wording from the response “We have updated our locum and agency staff induction, which includes signposting to the relevant documents on the intranet and on the Medusa system. All locum and agency staff, in conjunction with the local ward team complete an induction form which is subsequently sent to the Education Team who monitor adherence with the induction process.” Source location 2020-0186-Response-from-East-Suffolk-and-North-Essex_Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind nursing staff about the 24/7 Duty Matron and on-call consultants available for escalation and questions.
Verbatim wording from the response “All nursing staff have been reminded that there is a Duty Matron available 24/7 and consultants on-call, to whom all staff can escalate any concerns or ask questions, in addition to the Consultants on-call.” Source location 2020-0186-Response-from-East-Suffolk-and-North-Essex_Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Morphine and Naloxone Administration Guidelines in line with BNF guidance.
Verbatim wording from the response “We have reviewed and updated the ESNEFT Morphine Administration Guideline and the Naloxone Administration Guideline in line with those set out in the British National Formulary (BNF). Both guidelines have been communicated to staff through the Chief Medical Officer’s ‘Doctors Round’ and the guidelines are published on the Trust intranet and on the medications specific application ‘Medusa’ where they are easily accessible by staff in all areas within the Trust.” Source location 2020-0186-Response-from-East-Suffolk-and-North-Essex_Redacted.pdf
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations