Concerns raised 5 Insufficient detail in final investigation reports View source Factual errors and inaccuracies in initial investigation reports View source Delays in final investigation report completion View source Delays in HSIB investigation completion View source Restriction of Trust-led investigation during HSIB investigations View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
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 Jan 2015 Susanna Geraty · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Failure of SI reports to consider dehydration as a possible cause of acute renal failure View source Inadequacy of fluid balance charts View source Failure to assess and monitor post operative fluid balance View source Inadequacy of nursing records View source Failure to recognise an acutely unwell patient View source Failure to respond to legitimate concerns raised by the family View source Failure to record post operative fluid balance View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
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 Sep 2014 Hilda Florence Thompson · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Poor recording of falls-risk management View source Failure to complete the falls management plan View source Delays in putting falls-prevention measures into place View source Delays in reviewing and reassessing falls risk View source Failure to accurately identify falls risk View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
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
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations