East Surrey Hospital

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First report 3 Sep 2014•Latest report 20 Apr 2020

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 3
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from East Surrey Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

20 Apr2020
Surrey
Concerns raised5
1. Insufficient detail in final investigation reports
2. Factual errors and inaccuracies in initial investigation reports
3. Delays in final investigation report completion
1. Delays in HSIB investigation completion
2. Restriction of Trust-led investigation during HSIB investigations
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Theo Benjamin Young · 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

Theo Benjamin Young was born by emergency caesarean section in a very poor condition after persistent abnormalities in fetal monitoring were not recognised during labour. He suffered non-survivable injuries from intrapartum hypoxia and died three days after delivery. Concerns included failures in staffing, fetal monitoring, escalation and oxytocin management, as well as delays and deficiencies in the subsequent HSIB investigation.

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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Insufficient detail in final investigation reports
Wider context from the report
“3. The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death, during which time further deaths could have resulted. ”
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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Factual errors and inaccuracies in initial investigation reports
Wider context from the report
“3. The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death, during which time further deaths could have resulted. ”
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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in final investigation report completion
Wider context from the report
“3. The initial draft report contained factual errors and inaccuracies requiring considerable input by the Trust to resolve. The final report is insufficiently detailed and was completed 18 months after the death, during which time further deaths could have resulted. ”
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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in HSIB investigation completion
Wider context from the report
“2. HSIB indicated to the Trust at the outset that their investigation would take approximately six months which is highly likely to delay the introduction of any immediate necessary measures by the Trust to prevent further 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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Restriction of Trust-led investigation during HSIB investigations
Wider context from the report
“1. The HSIB specifically requested the Trust not to undertake their own investigation effectively preventing the recognition of causes of concern and therefore being unable to undertake any immediate and necessary remedial action at the earliest opportunity to prevent future deaths. ”
Open source report
27 Jan2015
Surrey
Concerns raised7
1. Failure of SI reports to consider dehydration as a possible cause of acute renal failure
2. Inadequacy of fluid balance charts
3. Failure to assess and monitor post operative fluid balance
1. Inadequacy of nursing records
2. Failure to recognise an acutely unwell patient
3. Failure to respond to legitimate concerns raised by the family
4. Failure to record post operative fluid balance
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Susanna Geraty · 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

Susanna Geraty, a previously fit and well 75-year-old woman, died after developing acute renal failure and hyperkalaemic cardiac arrest five days after surgery for a fractured tibia and fibula. The principal concerns were inadequate assessment, monitoring and recording of postoperative fluid balance, failure to respond promptly to family concerns or recognise her deteriorating condition, and an investigation report’s failure to consider dehydration as a possible cause of the acute renal failure.

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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of SI reports to consider dehydration as a possible cause of acute renal failure
Wider context from the report
“6. Failure of the SI report to consider or acknowledge dehydration as a possible cause of acute renal failure ”
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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inadequacy of fluid balance charts
Wider context from the report
“3. Inadequate fluid balance charts ”
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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to assess and monitor post operative fluid balance
Wider context from the report
“1. Failure to assess, monitor and record post operative fluid balance. ”
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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inadequacy of nursing records
Wider context from the report
“2. Inadequate nursing records ”
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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to recognise an acutely unwell patient
Wider context from the report
“5. Failure to recognise an acutely unwell 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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to respond to legitimate concerns raised by the family
Wider context from the report
“4. Failure to respond to legitimate concerns raised by the family ”
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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to record post operative fluid balance
Wider context from the report
“1. Failure to assess, monitor and record post operative fluid balance. ”
Open source report
3 Sep2014
Surrey
Concerns raised5
1. Poor recording of falls-risk management
2. Failure to complete the falls management plan
3. Delays in putting falls-prevention measures into place
1. Delays in reviewing and reassessing falls risk
2. Failure to accurately identify falls risk
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Hilda Florence Thompson · 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

Hilda Florence Thompson, who had limited mobility and a history of falls, was admitted to hospital with breathlessness and later identified as a high falls risk. She collapsed on 19 January 2014, sustained an extensive intracranial injury, and died on 22 January 2014; concerns included an incomplete admission management plan, incorrect initial identification as not being at risk of falls, delayed falls assessment, and poor record-keeping.

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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Poor recording of falls-risk management
Wider context from the report
“• Upon her admission to hospital, her management plan was not completed and she was wrongly identified as not being a falls risk. • There was no further review of Mrs Thompson and it was not until 11/1/14 when a full falls risk assessment was made and preventable measures put into place. • Poor note taking of 2/1/14 to account for this. • This left a gap of some 10 days during which she was not properly risk assessed for falls. ”
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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete the falls management plan
Wider context from the report
“• Upon her admission to hospital, her management plan was not completed and she was wrongly identified as not being a falls risk. • There was no further review of Mrs Thompson and it was not until 11/1/14 when a full falls risk assessment was made and preventable measures put into place. • Poor note taking of 2/1/14 to account for this. • This left a gap of some 10 days during which she was not properly risk assessed for falls. ”
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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in putting falls-prevention measures into place
Wider context from the report
“• Upon her admission to hospital, her management plan was not completed and she was wrongly identified as not being a falls risk. • There was no further review of Mrs Thompson and it was not until 11/1/14 when a full falls risk assessment was made and preventable measures put into place. • Poor note taking of 2/1/14 to account for this. • This left a gap of some 10 days during which she was not properly risk assessed for falls. ”
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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in reviewing and reassessing falls risk
Wider context from the report
“• Upon her admission to hospital, her management plan was not completed and she was wrongly identified as not being a falls risk. • There was no further review of Mrs Thompson and it was not until 11/1/14 when a full falls risk assessment was made and preventable measures put into place. • Poor note taking of 2/1/14 to account for this. • This left a gap of some 10 days during which she was not properly risk assessed for falls. ”
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 Surrey Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to accurately identify falls risk
Wider context from the report
“• Upon her admission to hospital, her management plan was not completed and she was wrongly identified as not being a falls risk. • There was no further review of Mrs Thompson and it was not until 11/1/14 when a full falls risk assessment was made and preventable measures put into place. • Poor note taking of 2/1/14 to account for this. • This left a gap of some 10 days during which she was not properly risk assessed for falls. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised5

Insufficient detail in final investigation reports

Factual errors and inaccuracies in initial investigation reports

Delays in final investigation report completion

Delays in HSIB investigation completion

Restriction of Trust-led investigation during HSIB investigations

Concerns raised7

Failure of SI reports to consider dehydration as a possible cause of acute renal failure

Inadequacy of fluid balance charts

Failure to assess and monitor post operative fluid balance

Inadequacy of nursing records

Failure to recognise an acutely unwell patient

Failure to respond to legitimate concerns raised by the family

Failure to record post operative fluid balance

Concerns raised5

Poor recording of falls-risk management

Failure to complete the falls management plan

Delays in putting falls-prevention measures into place

Delays in reviewing and reassessing falls risk

Failure to accurately identify falls risk