8 Jan 2026 David Joseph DUGDALE · Prevention of Future Deaths report East Sussex
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Concerns raised 3 Poor management of pain View source Failure to provide adequate pressure sore care View source Insufficient nutritional support for inpatients 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. 16
Action
Continue Trust-wide pressure-ulcer prevention work through category monitoring, monthly audits, CQUIN compliance oversight, and Pressure Ulcer Steering Group governance.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026. View source
Action
Implement an expedited fractured-hip and long-bone pain pathway, including prompt orthopaedic review, appropriate analgesia or nerve block, and a completed transfer pain checklist.
Stated plannedThe respondent said that this action was planned when they made their response on 9 January 2026. View source
Action
Circulate a Safety Pin to share pain-management learning and reinforce expectations across divisions.
Stated completedThe respondent said that this action was complete when they made their response on 9 January 2026. View source
Action
Continue targeted face-to-face pressure-ulcer training, circulate wound-care learning newsletters and webinars, and provide recurring ward study sessions.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026. View source
Action
Undertake a formal evaluation of the Trust mandatory training framework during 2026–27 and seek approval for resulting training changes.
Stated plannedThe respondent said that this action was planned when they made their response on 9 January 2026. View source
Action
Require structured at least-shiftly pain assessments for patients unable to self-report, incorporating learning-disability tools and carer or next-of-kin input.
Stated plannedThe respondent said that this action was planned when they made their response on 9 January 2026. View source
Action
Require admission liaison with carers and use “This Is Me” information to establish how patients express pain and what interventions work.
Stated plannedThe respondent said that this action was planned when they made their response on 9 January 2026. View source
Action
Deliver mandatory and essential wound-care training, including pressure-ulcer prevention, human factors, and simulated patient-safety scenarios for relevant clinical staff.
Stated completedThe respondent said that this action was complete when they made their response on 9 January 2026. View source
Action
Continue quarterly audits of MUST compliance, referral timeliness, and weight monitoring, with results reported through governance arrangements.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026. View source
Action
Escalate unresolved or carer-reported pain to same-shift senior nursing review and medical assessment, with documented care-plan adjustments and daily pain-checklist review.
Stated plannedThe respondent said that this action was planned when they made their response on 9 January 2026. View source
Action
Jointly plan care with carers and families at admission, document and act on concerns about pain, deterioration, or unmet needs, and improve communication through Trust and Sussex-wide programmes.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026. View source
Action
Audit pain-assessment documentation and escalation monthly, review results through Divisional Governance, and continue ward-round teaching on pain tools and documentation.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026. View source
Action
Run a BETU nutrition-improvement pilot using additional Dietetic staffing, equipment review, and strategies to improve nutrition, then roll learning out across the Trust.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 January 2026. View source
Action
Require admission and weekly MUST screening, real-time monitoring, automatic Dietetics referral for high risk or poor intake, and multidisciplinary review of repeated nutrition or hydration refusal.
Stated completedThe respondent said that this action was complete when they made their response on 9 January 2026. View source
Action
Provide specialist Learning Disability Nurse review within 48 hours of admission for patients with learning disabilities.
Stated plannedThe respondent said that this action was planned when they made their response on 9 January 2026. View source
Action
Use the electronic pressure-ulcer audit tool for monthly ward audits and monitor compliance against prevention and management criteria.
Stated completedThe respondent said that this action was complete when they made their response on 9 January 2026. View source See 13 more actions
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AI-generated summary
David Joseph DUGDALE · 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 Joseph Dugdale was admitted to hospital in January 2024, sustained bilateral hip fractures and developed a pressure sore, before undergoing surgery and dying on 19 May 2024. Concerns included inadequate pain management, insufficient nutritional support, deterioration of the pressure sore to grade 4, and poor nursing care, including soiled dressings and the sore being left exposed.
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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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor management of pain
Wider context from the report “1. Poor management of David's pain . In spite of sustaining a category 2 pressure sore and bilateral hip fractures whilst in patient at EDGH, he was only receiving oral paracetamol . Not until ambulance crew raised their concerns about his inadequate pain relief prior to their transferring him to Conquest Hospital did he receive increased and more appropriate pain relief. His carers repeatedly tried to advise nursing staff that he was in pain, but their concerns were not listened to nor acted upon .
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate pressure sore care
Wider context from the report “3. The pressure sore deteriorated to grade 4 during his admission which was a direct cause of his death. He was often found lying in soiled dressings with his pressure sore exposed and in pain by his visiting carers.
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient nutritional support for inpatients
Wider context from the report “2. David lost 3kgs in weight during the first month of his admission to EDGH. He was not eating nor drinking. There seemed to be little nutritional support available to David in the early stages of his admission causing him to lose almost 30kgs in total.
” 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 Continue Trust-wide pressure-ulcer prevention work through category monitoring, monthly audits, CQUIN compliance oversight, and Pressure Ulcer Steering Group governance.
Verbatim wording from the response “Alongside the above, the PUSG plans several educational and promotional events for staff and patients during national ‘Stop the Pressure Week’ in November. These events rotate between hospital sites and community locations to encourage a range of attendees from all settings. The programme of events for these days is planned and coordinated by the tissue viability team and are designed to meet the most recent priorities or areas for improvement identified by learning from incidents and Inquests (attachments F&G). A programme of work/activity is developed annually by the Trust Pressure Ulcer Steering Group (PUSG) to reduce risk of pressure damage based on learning from previous incidents, Inquests, audit findings and national guidance and recommendations.” Source location Response from East Sussex Healthcare NHS 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 an expedited fractured-hip and long-bone pain pathway, including prompt orthopaedic review, appropriate analgesia or nerve block, and a completed transfer pain checklist.
Verbatim wording from the response “timely intervention. Care plans are to be adjusted based on the patient's response to analgesia, with clear and concise documentation. Regular communication is maintained between medical teams, nursing staff, carers, next-of-kin, HCAs, and the Pain Team to ensure optimal pain management. For patients with fractured hip, neck of femur, or long-bone injuries, pain management should be initiated immediately and without delay, including iliopsoas Iliac Nerve Block by trained clinicians in addition to Morphine, Buprenorphine patch, intravenous paracetamol etc. unless contraindicated. Orthopaedic teams will provide prompt review across both sites, and transfers from Eastbourne District General Hospital to Conquest via ambulance will require a completed a neck of femur fracture pain checklist to ensure adequate pain control prior to movement.” Source location Response from East Sussex Healthcare NHS 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 Circulate a Safety Pin to share pain-management learning and reinforce expectations across divisions.
Verbatim wording from the response “Definitive pain management of fractured neck of femur/long bones will be under the Orthopaedic team (surgical management) and a Safety Pin (attachment A) has also been circulated to share learning across divisions and reinforce expectations.” Source location Response from East Sussex Healthcare NHS 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 Continue targeted face-to-face pressure-ulcer training, circulate wound-care learning newsletters and webinars, and provide recurring ward study sessions.
Verbatim wording from the response “The Tissue Viability Nurses regularly provide targeted face to face training in wards and departments where requested. These can be ad hoc in response to incidents or identified knowledge gaps by department leads or on pre-planned routine ward study days with several topics covered, similar to BETU ward. Wards such as Cuckmere ward have received face to face training sessions, with some receiving ongoing 1-hour sessions monthly and pressure ulcer training every 2 months. BETU ward have introduced PFD focused study days in 2025/26 which include 2-hour face to face pressure ulcers sessions. The training being provided also incorporates the Pressure Ulcer Prevention Policy update, dated 15/10/2025 (attachment E), the review of Nevercentre pressure ulcer documentation and the importance of medical photography in supporting pressure ulcer management and surveillance.” Source location Response from East Sussex Healthcare NHS 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 Undertake a formal evaluation of the Trust mandatory training framework during 2026–27 and seek approval for resulting training changes.
Verbatim wording from the response “As part of the QI project commissioned by the Pressure Ulcer Steering Group (PUSG) on Benson and Egerton Trauma Unit (BETU), additional bitesize face to face training has been piloted on the ward and on bespoke study days. The feedback and evaluation have been positive and reported back to the PUSG with a strong preference for face-to-face learning compared to mandatory eLearning. In turn PUSG requested the NHS Sussex Wound Care Group undertake an evaluation of the mandatory training framework, however the group disbanded in early 2026. As a result, the PUSG is planning to undertake a formal evaluation” Source location Response from East Sussex Healthcare NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require structured at least-shiftly pain assessments for patients unable to self-report, incorporating learning-disability tools and carer or next-of-kin input.
Verbatim wording from the response “We recognise that Mr Dugdale did not receive adequate pain relief and recognition of pain in non-verbal, vulnerable, and learning-disabled patients was not of a standard we expect; in response, the following measures are to be implemented immediately. On admission clinical teams are to liaise directly with family members and carers to establish how the patient typically expresses pain and what interventions have previously been effective. “This Is Me” documentation is requested to support the multidisciplinary team in understanding the patient’s individual needs. All patients who are unable to reliably self-report pain receive a structured pain assessment at least once per shift, using the learning disability pain tool and incorporating carer or next-of-kin input, with care-home documentation used where available.” Source location Response from East Sussex Healthcare NHS 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 Require admission liaison with carers and use “This Is Me” information to establish how patients express pain and what interventions work.
Verbatim wording from the response “We recognise that Mr Dugdale did not receive adequate pain relief and recognition of pain in non-verbal, vulnerable, and learning-disabled patients was not of a standard we expect; in response, the following measures are to be implemented immediately. On admission clinical teams are to liaise directly with family members and carers to establish how the patient typically expresses pain and what interventions have previously been effective. “This Is Me” documentation is requested to support the multidisciplinary team in understanding the patient’s individual needs. All patients who are unable to reliably self-report pain receive a structured pain assessment at least once per shift, using the learning disability pain tool and incorporating carer or next-of-kin input, with care-home documentation used where available.” Source location Response from East Sussex Healthcare 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 Deliver mandatory and essential wound-care training, including pressure-ulcer prevention, human factors, and simulated patient-safety scenarios for relevant clinical staff.
Verbatim wording from the response “We also worked in partnership with NHS Sussex and other health care providers in Sussex to agree a mandatory framework for education and training related to wound care for clinical staff including pressure ulcers in line with the National Wound Care Strategy Programme (NWCSP). This includes eLearning and face to face taught elements and different tiers or levels of training are required for staff in different roles (attachment D). The Tissue Viability Nurses also provide face to face training as part of the mandatory induction and preceptorship training for newly qualified or new to Trust nurses. In addition to the mandatory training, the Trust has also introduced essential training days for clinical staff which provides training in human factors and simulated scenarios related to patient safety, for a blended and interactive approach to learning.” Source location Response from East Sussex Healthcare NHS 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 Continue quarterly audits of MUST compliance, referral timeliness, and weight monitoring, with results reported through governance arrangements.
Verbatim wording from the response “To ensure improvements are maintained and monitored over time, quarterly audits will review MUST compliance, referral timelines, and weight-monitoring practices. LiveFlo monitoring by Matrons and Heads of Nursing will continue to support real-time oversight, and audit results will be reported through the IGM. Immediate reinforcement of these expectations has already taken place, audit results from 2025 are already available and outlined below but we will continue an audit cycle within three to six months.” Source location Response from East Sussex Healthcare 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 Escalate unresolved or carer-reported pain to same-shift senior nursing review and medical assessment, with documented care-plan adjustments and daily pain-checklist review.
Verbatim wording from the response “Any unresolved pain following simple analgesia, or pain reported by carers, triggers a same-shift senior nurse review and medical escalation. In addition, the Learning Disability Nurse completes and documents a specialist review within 48 hours of admission for all patients with a learning disability.” Source location Response from East Sussex Healthcare 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 Jointly plan care with carers and families at admission, document and act on concerns about pain, deterioration, or unmet needs, and improve communication through Trust and Sussex-wide programmes.
Verbatim wording from the response “The Trust acknowledges the risk associated with failing to respond to repeated concerns raised by carers, and several actions have been implemented to strengthen listening, communication, and escalation culture. On the day of admission, or as close to this as possible, ward staff now jointly plan care with carers and family members to establish an agreed baseline and clarify how changes in the patient’s condition, such as how they express pain, should be communicated. All concerns raised by carers regarding pain,” Source location Response from East Sussex Healthcare NHS 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 Audit pain-assessment documentation and escalation monthly, review results through Divisional Governance, and continue ward-round teaching on pain tools and documentation.
Verbatim wording from the response “To provide assurance of sustained improvement, monthly audits of pain assessment documentation and escalation actions are now in place with the first audit scheduled within three months. Audit outcomes are to be reviewed at Divisional Governance, with escalation for sustained non-compliance. Ongoing teaching of the learning disability pain tool and documentation standards occur during daily medical/surgical ward rounds with priority on using the learning disability pain tool to help in pain assessment/management in cases of learning difficulty, non-verbal and vulnerable patients. We will continue to reinforce the importance of Orthopaedic and Orthogeriatric documentation relating to pain management and checklist.” Source location Response from East Sussex Healthcare 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 Run a BETU nutrition-improvement pilot using additional Dietetic staffing, equipment review, and strategies to improve nutrition, then roll learning out across the Trust.
Verbatim wording from the response “Following these results, a pilot project has recently commenced on BETU to look at improving nutritional standards on this ward. This involves additional Dietetic staffing to improve training, review of the equipment available for measuring nutritional status and trialling strategies to improve provision of high-quality nutrition on the ward. Learning from this project will be rolled out to the wider Trust.” Source location Response from East Sussex Healthcare 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 Require admission and weekly MUST screening, real-time monitoring, automatic Dietetics referral for high risk or poor intake, and multidisciplinary review of repeated nutrition or hydration refusal.
Verbatim wording from the response “Completing the Malnutrition Universal Screening Tool (MUST), a tool used to identify adults who are malnourished or at risk of malnutrition, is now required on admission and weekly as a minimum. These should be monitored by ward Matrons and Heads of Nursing using the LiveFlo system, if a MUST score is 2 or above or there is documented poor oral intake for more than 48 hours this will trigger an automatic referral to Dietetics. In addition, nutritional plans must be clearly referenced within daily nursing documentation and where patients repeatedly refuse nutrition or hydration, this will trigger a multidisciplinary review (MDT) involving Dietetics and the Learning Disability Nurse, ensuring that barriers to intake are explored and addressed promptly. These measures are designed to ensure that nutritional concerns are escalated early and managed proactively.” Source location Response from East Sussex Healthcare NHS 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 Provide specialist Learning Disability Nurse review within 48 hours of admission for patients with learning disabilities.
Verbatim wording from the response “Any unresolved pain following simple analgesia, or pain reported by carers, triggers a same-shift senior nurse review and medical escalation. In addition, the Learning Disability Nurse completes and documents a specialist review within 48 hours of admission for all patients with a learning disability.” Source location Response from East Sussex Healthcare NHS 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 Use the electronic pressure-ulcer audit tool for monthly ward audits and monitor compliance against prevention and management criteria.
Verbatim wording from the response “As such there have been several actions that have since been undertaken since April 2024 to achieve and maintain long term effectiveness with our improvements. These have been led by the Pressure Ulcer Steering Group (PUSG) and the Tissue Viability Specialist Nurses. We have identified areas for improvement including maternity, elective care, and gateway areas. A new electronic audit tool was designed and implemented in August 2025 after a pilot, whereby audits are now undertaken monthly by each ward auditing a minimum of 20 patients.” Source location Response from East Sussex Healthcare NHS Trust
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14 May 2024 Carol Ann DIVALL · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 9 Failure to provide two-hourly repositioning View source Failure to provide accurate and complete discharge information View source Failure to conduct a sufficient and comprehensive root cause analysis View source Failure to provide basic nursing oral care View source Delays in referral to tissue viability specialists View source Failure to maintain pressure-relieving mattress function View source Failure to provide regular mobilisation assistance View source Delays in providing nutritional supplementation View source Failure to provide and continue treatment for oral thrush View source See 6 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
Carol Ann DIVALL · 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
Carol Ann DIVALL had Alzheimer's disease and sustained a hip fracture at home on 15 September 2022, which was surgically repaired during a hospital admission. She was discharged on 24 October 2022 for end-of-life care and died at home on 29 October 2022. Concerns included severe oral thrush and malnutrition, limited mobilisation, development and deterioration of a grade 4 sacral pressure sore, and misleading or incomplete discharge documentation and investigation.
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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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide two-hourly repositioning
Wider context from the report “C. Mrs Divall developed a grade 4 sacral pressure sore. She was not referred to the Tissue Viability Nurse until 1.10.22 who confirmed in her evidence that it would have taken 12-14 days to develop and would therefore have been available to be seen by the nursing staff caring for her. Contributing to the deterioration of her pressure sore was the deflating of her hybrid mattress on at least 2 occasions. Mr Divall noticed who visited for long periods every day noticed that his wife was never repositioned as she should have been on a 2 hourly basis at any time during his daily visits. I consider that Mrs Divall's immobility and malnourishment contributed to the development of her pressure sore the care of and severity were not mentioned in the discharge summary.
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate and complete discharge information
Wider context from the report “D. The Discharge Summary was misleading to the District Nurses who were unaware of the severity of Mrs Divall's pressure sore until they saw it (down to the bone) and did not make clear that Mrs Divall had been discharged for end of life care .
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a sufficient and comprehensive root cause analysis
Wider context from the report “E. The RCA was insufficient and did not address all of the issues surrounding Mrs Divall's care nor did it properly address those issues it did consider.
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide basic nursing oral care
Wider context from the report “A. That Mrs Divall developed severe oral thrush making it very difficult for her to eat and drink and take her oral medication. She was referred to the dietitians on 2.10.22 and triaged by an Assistant the following day. She was not prescribed Fortisip until 14.10.22 by which time she was becoming malnourished. The oral thrush continued until discharge. Nystatin appeared to be prescribed once on 12.10.22 and was not prescribed on discharge nor mentioned in the discharge summary. I heard evidence on PFD matters that software which requires a clinician to check oral care is being implemented. I remain of the opinion that this forms part of basic nursing care which was overlooked in Mrs Divall's case.
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in referral to tissue viability specialists
Wider context from the report “C. Mrs Divall developed a grade 4 sacral pressure sore. She was not referred to the Tissue Viability Nurse until 1.10.22 who confirmed in her evidence that it would have taken 12-14 days to develop and would therefore have been available to be seen by the nursing staff caring for her. Contributing to the deterioration of her pressure sore was the deflating of her hybrid mattress on at least 2 occasions. Mr Divall noticed who visited for long periods every day noticed that his wife was never repositioned as she should have been on a 2 hourly basis at any time during his daily visits. I consider that Mrs Divall's immobility and malnourishment contributed to the development of her pressure sore the care of and severity were not mentioned in the discharge summary.
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain pressure-relieving mattress function
Wider context from the report “C. Mrs Divall developed a grade 4 sacral pressure sore. She was not referred to the Tissue Viability Nurse until 1.10.22 who confirmed in her evidence that it would have taken 12-14 days to develop and would therefore have been available to be seen by the nursing staff caring for her. Contributing to the deterioration of her pressure sore was the deflating of her hybrid mattress on at least 2 occasions. Mr Divall noticed who visited for long periods every day noticed that his wife was never repositioned as she should have been on a 2 hourly basis at any time during his daily visits. I consider that Mrs Divall's immobility and malnourishment contributed to the development of her pressure sore the care of and severity were not mentioned in the discharge summary.
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide regular mobilisation assistance
Wider context from the report “B. Mrs Divall was referred to the Physiotherapy Department 2 weeks after admission but was rarely assisted with mobilisation and left to sit out in her chair for long periods . Action should have been taken to encourage Mrs Divall to mobilise more often in an attempt to rehabilitate her after her surgery.
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in providing nutritional supplementation
Wider context from the report “A. That Mrs Divall developed severe oral thrush making it very difficult for her to eat and drink and take her oral medication. She was referred to the dietitians on 2.10.22 and triaged by an Assistant the following day. She was not prescribed Fortisip until 14.10.22 by which time she was becoming malnourished. The oral thrush continued until discharge. Nystatin appeared to be prescribed once on 12.10.22 and was not prescribed on discharge nor mentioned in the discharge summary. I heard evidence on PFD matters that software which requires a clinician to check oral care is being implemented. I remain of the opinion that this forms part of basic nursing care which was overlooked in Mrs Divall's case.
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide and continue treatment for oral thrush
Wider context from the report “A. That Mrs Divall developed severe oral thrush making it very difficult for her to eat and drink and take her oral medication. She was referred to the dietitians on 2.10.22 and triaged by an Assistant the following day. She was not prescribed Fortisip until 14.10.22 by which time she was becoming malnourished. The oral thrush continued until discharge. Nystatin appeared to be prescribed once on 12.10.22 and was not prescribed on discharge nor mentioned in the discharge summary. I heard evidence on PFD matters that software which requires a clinician to check oral care is being implemented. I remain of the opinion that this forms part of basic nursing care which was overlooked in Mrs Divall's case.
” 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 Remind ward staff to offer suitable nourishing drinks before dietitian review and promote high-calorie, high-protein ward options.
Verbatim wording from the response “Following the completion of the MUST or mouthcare assessment on admission, the dietitians will have base line information to work from to enable a full assessment of the patient. Any concerns are highlighted to dietitians via the referral process and from communication with the MDT, patient and family. As part of the learning implemented following Mrs Divall’s experience, all ward staff have received escalated communications to remind them that they can offer nourishing drinks such as Complan shakes and thickened yoghurts prior to dietitian referral or review, as long as there are no concerns about swallowing difficulties/dysphagia. The Dietetic team additionally promote the availability of high calorie, high protein options on the wards to staff and patients.” Source location Response from East Sussex Healthcare
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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 electronic prescribing and medicines administration to reduce missed medicines.
Verbatim wording from the response “We accept that the medical records show the prescription of Nystatin was not continued onto the next weekly paper medication chart when the previous one was full. We have recently introduced Electronic Prescribing & Medicines Administration (EPMA) system where the risk of a medication being missed is far reduced as the medication will stay on the system until the course is finished or stopped. We anticipate undertaking an audit of the new EPMA system within this financial year to review the impact on missed medication.” Source location Response from East Sussex Healthcare
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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 Develop and pilot a flow chart for recognising end-of-life patients and selecting appropriate care pathways.
Verbatim wording from the response “With regard to concerns around End-of-Life Care (EOL), from our documentation it was not recognised that Mrs Divall was EOL, and she was therefore not referred to the Specialist Palliative Care Team and this was not described on her discharge documentation. As a result, we have developed a pilot flow chart for recognising EOL. Once piloted, the intention is to share this throughout our hospitals, see Attachment E.” Source location Response from East Sussex Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct regular senior nurse-led audits of compliance with MUST treatment plans.
Verbatim wording from the response “We have developed regular senior nurse-led audits to measure the quality of compliance with the treatment plan for MUST. Plans are also in place for a Trust wide audit of the quality MUST assessments, including evidence of treatments commenced.” Source location Response from East Sussex Healthcare
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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 Develop and implement the 5P discharge process for communicating significant pressure damage.
Verbatim wording from the response “The Chief Nurse has proposed a new process called the ‘5P Process for Discharge’ to improve the communication related to significant pressure damage on discharge. This has been presented and discussed at length with senior nurses across the organisation and is currently being developed and implemented. The process includes utilising our medical illustration team to take clear images of wounds for sharing with carers with consent as required. We have included a copy of the process as Attachment A, and a copy of the 5P slide deck at Attachment B.” Source location Response from East Sussex Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the completed Trust-wide inpatient-bed audit to determine effective next steps for mattress protection.
Verbatim wording from the response “We note the failure of the hybrid mattress pump in this case. Even in the event of failure, we would anticipate that the mattress provides sufficient protection to patients at risk of pressure damage, however we note this did not happen in this case. We recently completed a Trust-wide audit of all inpatient beds to understand the current picture and are considering the findings in order to ensure effective next steps.” Source location Response from East Sussex Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Saturday physiotherapy assessments for new fractured-neck-of-femur patients.
Verbatim wording from the response “When Mrs Divall was an in-patient, we did not have a routine Physiotherapy weekend service and had experienced staff sickness as well. We have now made changes to the rota for this service and since mid-May we now have a Saturday service for new assessments of patients who have sustained a fractured Neck of Femur.” Source location Response from East Sussex Healthcare
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 quality documentation and discharge-checklist audits to identify and correct communication failures.
Verbatim wording from the response “By applying this approach to the care delivered to Mrs Divall the Trust acknowledge and accept the concerns of the Coroner. We are aware we need to review and improve our communication with next of kin and, as above, between teams on discharge such as the District Nurses and ward to ensure important information is cascaded avoiding confusion and distress to families. We now have bimonthly Quality Summits which all the Ward Matrons will be attending in person to emphasise the importance of communication between families but also between staff in order to ensure that care provided is of the highest quality. We have also developed quality documentation audits and discharge checklist audits so that where we see a miscommunication we can put it right in the moment.” Source location Response from East Sussex Healthcare
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 Audit the impact of electronic prescribing and medicines administration on missed medication.
Verbatim wording from the response “We accept that the medical records show the prescription of Nystatin was not continued onto the next weekly paper medication chart when the previous one was full. We have recently introduced Electronic Prescribing & Medicines Administration (EPMA) system where the risk of a medication being missed is far reduced as the medication will stay on the system until the course is finished or stopped. We anticipate undertaking an audit of the new EPMA system within this financial year to review the impact on missed medication.” Source location Response from East Sussex Healthcare
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 Trust-wide audit of MUST assessment quality and treatment evidence.
Verbatim wording from the response “We have developed regular senior nurse-led audits to measure the quality of compliance with the treatment plan for MUST. Plans are also in place for a Trust wide audit of the quality MUST assessments, including evidence of treatments commenced.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and use a pressure-ulcer After Action Review template under the Patient Safety Incident Response Framework.
Verbatim wording from the response “Under the NHS England’s Patient Safety Incident Response Framework (PSIRF) the Trust have developed a Pressure Ulcer After Action Review (AAR) template in collaboration with the TVN's and the Pure Ulcer Review Group (PURG) – see Attachment F. The aim of PSIRF is to apply a broader approach to addressing patient safety issues, such as pressure ulcers, taking the focus away from investigating individual incidents to instead focus on” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update Dietetic Assistant competencies and provide training and support on accurate referral coding.
Verbatim wording from the response “Turning to the prescription of Fortisip, this is typically undertaken following a registered dietitian’s assessment. We accept that doctors could have prescribed this prior to review by a dietitian in this case. On this occasion due to a coding error at the point of triage, the urgency of our response is not as it should have been. Dietetic Assistant (DA) competencies have now been updated and additional training and support are given to DAs regarding the importance of coding correctly at this point in the pathway, to minimise the potential for recurrence of this error.” Source location Response from East Sussex Healthcare
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 Increase physical therapy capacity by employing two full-time Physical Therapist Assistants.
Verbatim wording from the response “We have also increased staffing to include two full-time Physical Therapist Assistants (PTAs) in the period since this incident.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a dedicated Mouth Care Matters Lead role and deliver targeted mouthcare training.
Verbatim wording from the response “The Trust has now established a role (the ‘Mouth Care Matters’ Lead) that is dedicated to the promotion of good standards of mouthcare for patients and targeted training is delivered as per requirements and individual patient need (for example, in the event of a patient who is distressed or failing to comply, additional support and training would be available to staff providing care).” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and publish a District Nurse referral flow chart specifying information required for fast-track discharge.
Verbatim wording from the response “To address these information concerns, we have developed a flow chart on how to refer to District Nurses and what information needs to be shared to support decision making and tasks related to fast track discharge, available on the extranet and in the discharge policy.” Source location Response from East Sussex Healthcare
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 Share the end-of-life recognition flow chart throughout the hospitals after piloting.
Verbatim wording from the response “With regard to concerns around End-of-Life Care (EOL), from our documentation it was not recognised that Mrs Divall was EOL, and she was therefore not referred to the Specialist Palliative Care Team and this was not described on her discharge documentation. As a result, we have developed a pilot flow chart for recognising EOL. Once piloted, the intention is to share this throughout our hospitals, see Attachment E.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete daily hybrid-mattress-pump checks in pilot wards and address identified equipment issues.
Verbatim wording from the response “Additionally, as part of the QI project noted above, Benson Ward and Egerton Trauma Unit now complete daily checks on all hybrid mattress pumps and this is documented on a checklist (Attachment C). Actions are taken to supply pumps to those patients that need them (as all mattresses are hybrid) and address any issues with teams on the ward, who are” Source location Response from East Sussex Healthcare
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 Maintain electronic MUST and mouthcare assessments to record and monitor patient care.
Verbatim wording from the response “We recognise that the mouthcare received by Mrs Divall was not of a standard we expect. Since 2022 the Malnutrition Universal Screening Tool (MUST) and Mouthcare assessment have been a central element of basic documentation. At the end of last year both documents were transferred to an electronic system, to enable staff to record and monitor the care provided to patients, with a decreased risk of losing manual recording.” Source location Response from East Sussex Healthcare
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 pressure-ulcer prevention and management quality-improvement project with Tissue Viability Team support.
Verbatim wording from the response “In order to strengthen the approach regarding managing pressure sores, the Tissue Viability Team are supporting the ward to undertake a quality improvement (QI) project in relation to the prevention and management of pressure ulcers including the recognition of potential skin damage likely to deteriorate. This is especially relevant to patients who have a history of trauma which often incorporates frailty, poor health and a long lie prior to their admission to the ward. The success of the interventions on this QI project to reduce pressure ulcers in the unit will be reviewed and recommendations extended across the organisation in all wards.” Source location Response from East Sussex Healthcare
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 Share learning from the hybrid-mattress-pump pilot areas across the Trust.
Verbatim wording from the response “supported by ‘trouble-shooting’ sheets (see attachment D). It is our intention to take learnings from these pilot areas and share across the Trust.” Source location Response from East Sussex Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide risk-based scheduled mouthcare reviews with electronic prompts and escalation of missed reviews.
Verbatim wording from the response “High risk patients now receive daily mouthcare reviews, medium risk patients are reviewed every other day, and low risk patients are reviewed every third day ensuring that any oral concerns are picked up in a timely manner and managed until improvement is seen. All reviews are prompted on the electronic system and highlighted if not actioned.” Source location Response from East Sussex Healthcare
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 A failed hybrid mattress pump would ordinarily still provide sufficient protection against pressure damage, although it did not do so in this case.
Verbatim wording from the response “We note the failure of the hybrid mattress pump in this case. Even in the event of failure, we would anticipate that the mattress provides sufficient protection to patients at risk of pressure damage, however we note this did not happen in this case. We recently completed a Trust-wide audit of all inpatient beds to understand the current picture and are considering the findings in order to ensure effective next steps.” Source location Response from East Sussex Healthcare
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 RCA was specifically scoped to pressure ulcers, so it did not address other care concerns that were not identified during admission.
Verbatim wording from the response “E. The RCA was insufficient and did not address all of the issues surrounding Mrs Divall's care nor did it properly address those issues it did consider.” Source location Response from East Sussex Healthcare
Open published response
16 Jun 2022 James Joseph MANNING · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 14 Lack of a written procedure for making a 999 emergency call View source Lack of a national system for managing and sharing Health and Safety information across company sites View source Lack of guidance for urgent referral of children to hospital or tertiary care View source Lack of a written procedure for obtaining first aid help quickly View source Failure to provide adequately for visitors' first aid needs across sites View source Insufficient availability of AEDs in key site areas View source Lack of national guidance for consistent referral of children for tonsillectomy and similar treatment View source Failure to provide direct ENT referral or follow-up assessment after a child chokes View source Insufficiently robust incident investigation and reporting system View source Delays in reassessment and referral of urgent cases due to inadequate cover View source Inadequate systems for reviewing local information sharing View source Unavailability of an external phone line for emergencies View source Failure to communicate specialist referral priorities to local hospitals View source Absence of choking-related red flags in tonsillectomy guidance View source See 11 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
James Joseph MANNING · 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
James Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.
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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a written procedure for making a 999 emergency call
Wider context from the report “e) Witnesses confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999-emergency call especially if a trained first aider is not immediately available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a national system for managing and sharing Health and Safety information across company sites
Wider context from the report “a) From speaking to a number of witnesses in this case, I was deeply concerned that there was no national system for managing Health & Safety issues across company sites . Staff agreed it would help to share information and learning on a reciprocal basis across all sites .
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for urgent referral of children to hospital or tertiary care
Wider context from the report “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment. In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care ; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide.
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a written procedure for obtaining first aid help quickly
Wider context from the report “e) Witnesses confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999-emergency call especially if a trained first aider is not immediately available .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequately for visitors' first aid needs across sites
Wider context from the report “c) I am concerned that the Health & Safety Executive’s strong recommendation in the First Aid Regulations to consider the first aid of visitors and what will be offered in terms of provision across each site was not sufficiently reflected in company practices .
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of AEDs in key site areas
Wider context from the report “d) I was concerned to hear evidence that many months after this tragic incident during Tots Week, installation of an external phone line and sufficient AEDs in key areas such as restaurants and swimming pool areas had not been completed .
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for consistent referral of children for tonsillectomy and similar treatment
Wider context from the report “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment . In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide.
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide direct ENT referral or follow-up assessment after a child chokes
Wider context from the report “b) I also heard evidence from experts that when a child chokes as James did in May 2017, the risk of a life-threatening event is high. I was concerned to hear that A&E paediatricians could either refer directly to ENT specialists or arrange a follow-up visit to assess the likelihood of a repeat choking episode but in this case the child’s mother was referred back to the GP .
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust incident investigation and reporting system
Wider context from the report “b) After hearing extensive evidence, I was deeply concerned about whether there was a sufficiently robust incident investigation and reporting system in place so that lessons could be learned then shared with staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reassessment and referral of urgent cases due to inadequate cover
Wider context from the report “c) I heard evidence that at some points in James’s medical care there were delays in being reassessed especially following the sleep study . The delay in being reassessed and referred to tertiary care was contributed to by medical staff being off leave. Doctors will inevitably have leave yet I am still concerned that systems in place at that time were not sufficiently robust to ensure suitable cover was in place to progress urgent cases .
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate systems for reviewing local information sharing
Wider context from the report “f) At several points during the inquest, questions were asked of medical witnesses about how best practice is shared between local NHS Trusts and GP surgeries. I am concerned that systems to review how information is shared locally may need to be reconsidered .
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an external phone line for emergencies
Wider context from the report “d) I was concerned to hear evidence that many months after this tragic incident during Tots Week, installation of an external phone line and sufficient AEDs in key areas such as restaurants and swimming pool areas had not been completed .
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate specialist referral priorities to local hospitals
Wider context from the report “d) I also heard evidence to suggest that locally devised priorities agreed in specialist or tertiary centres (in this case the Royal Sussex County Hospital, Brighton) had not been communicated to local hospitals and shared so that doctors making a referral can consider the best place to refer a case taking into consideration relative waiting times .
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of choking-related red flags in tonsillectomy guidance
Wider context from the report “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment. In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide .
” Open source report
17 Jan 2018 Barry John TUCKER · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 8 Failure to provide enhanced recovery paperwork View source Failure to provide the enhanced recovery cystectomy leaflet View source Inadequate continuity and completeness of hospital notes View source Unavailability of senior urology input during admission View source Unavailability of enhanced recovery nurse specialist support during admission View source Lack of a coherent urology enhanced recovery discharge planning protocol View source Lack of pre-operative preparation View source Failure of the system for recalling discharged urology patients by ambulance View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Barry John TUCKER · 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
The supplied text does not describe the circumstances of Barry John TUCKER’s death beyond recording that an inquest took place. Concerns included lack of pre-operative preparation and senior clinical input, absent enhanced-recovery support and information, inadequate hospital notes, flawed ambulance recall arrangements, and no coherent discharge-planning protocol for enhanced-recovery urology procedures.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide enhanced recovery paperwork
Wider context from the report “(3) The Enhanced Recovery Nurse Specialist was also away during his admission. He never met her or received any paperwork from her
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the enhanced recovery cystectomy leaflet
Wider context from the report “(4) He never received a copy of the leaflet “Enhanced Recovery after having a Cystectomy” .
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate continuity and completeness of hospital notes
Wider context from the report “(5) Mr. Tucker’s hospital notes from arriving on Michelham Ward were suboptimal, lacking continuity, incomplete and unhelpful .
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of senior urology input during admission
Wider context from the report “(2) The Urology Consultant Surgeon was away during his admission and he had no senior input .
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of enhanced recovery nurse specialist support during admission
Wider context from the report “(3) The Enhanced Recovery Nurse Specialist was also away during his admission . He never met her or received any paperwork from her
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a coherent urology enhanced recovery discharge planning protocol
Wider context from the report “(7) There is no coherent discharge planning protocol in place for enhanced recovery procedures in respect of urology patients .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of pre-operative preparation
Wider context from the report “(1) Mr. Tucker received no pre-op preparation .
” 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 Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the system for recalling discharged urology patients by ambulance
Wider context from the report “(6) Eastbourne District General Hospital’s system for recalling patients to the Urology ward following discharge, if they need to go in by ambulance, is flawed .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and circulate updated cystectomy pathway documentation covering enhanced recovery, patient information and discharge requirements.
Verbatim wording from the response “Trust Response
There is a care pathway document for Cystectomy patients which contains detailed discharge planning information, including prompts and checks which assist in documenting the key stages of the post-operative period and plan of care. That care pathway documentation was not used and the nursing and medical notes do not contain a great deal of detail of Mr Tucker’s post-operative progress. The Trust acknowledges the learning opportunity presented here and has implemented the action plan below.” Source location 2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend postoperative daily-round documentation to capture greater detail on patient progress against the care plan.
Verbatim wording from the response “There are daily ward round records from the medical team, which provide a comprehensive record of the post-operative round which reflects the key stages in post-operative recovery, however they contained limited detail as to how Mr Tucker progressed against the plan.” Source location 2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the cystectomy pathway documentation for all relevant surgical cases.
Verbatim wording from the response “Recommendation: The Cystectomy Pathway patient documentation must be updated and used for all surgical cases no matter what ward to include the latest Cystectomy Enhanced Recovery Preparation Event and Recovery Pathway (CEPER) guidance and ensure clear to what patient information is provided and when (with sign off to state completed) and the discharge process/requirements;” Source location 2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review funding for a second Enhanced Recovery nurse and submit the application for consideration.
Verbatim wording from the response “Recommendation | Action | Source of assurance action embedded in practice | Lead | Deadline | Date completed
Review the request for funding a second ERAS nurse and if not possible ensure that appropriate mitigations and leave cover arrangements are put in place. | Ward team to be aware of ERAS nurse leave and provide the expertise. Application for second ERAS nurse to nurse division | ERAS support evident in patient notes and process for leave cover to be monitored | Head of Nursing | May 2018 |” Source location 2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the urology discharge process and maintain a discharge protocol for enhanced recovery patients.
Verbatim wording from the response “(7) There is no coherent discharge planning protocol in place for enhanced recovery procedures in respect of urology patients” Source location 2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign patients to a consultant who is present or arrange consultant cover during leave.
Verbatim wording from the response “Recommendation | Action | Source of assurance action embedded in practice | Lead | Deadline | Date completed
Patients must be assigned to a consultant who is present (to see the patient or cover for the consultant of the week to cover for annual or study leave) | Discussed at Clinical Governance meetings | Observed at safety huddle on ward | Clinical lead | Feb 2018 | 1 Feb 2018
Patients must be reviewed by consultant daily post-operatively. | Job plan to be amended to include daily rounds | Audit of notes in 3 months to ensure daily consultant review has taken place | Clinical lead | Job plan amended Feb 2018 for audit May 2018” Source location 2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend consultant job plans to require daily postoperative rounds.
Verbatim wording from the response “Recommendation | Action | Source of assurance action embedded in practice | Lead | Deadline | Date completed
Patients must be assigned to a consultant who is present (to see the patient or cover for the consultant of the week to cover for annual or study leave) | Discussed at Clinical Governance meetings | Observed at safety huddle on ward | Clinical lead | Feb 2018 | 1 Feb 2018
Patients must be reviewed by consultant daily post-operatively. | Job plan to be amended to include daily rounds | Audit of notes in 3 months to ensure daily consultant review has taken place | Clinical lead | Job plan amended Feb 2018 for audit May 2018” Source location 2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a urology specialty documentation audit to identify gaps, themes and improvements.
Verbatim wording from the response “Recommendation: Urology specialty documentation audit to identify themes and improvements in documentation.” Source location 2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pre-operative preparation occurred through assessment by a nurse and consultant anaesthetist; the concern that no preparation occurred is disputed.
Verbatim wording from the response “(1) Mr Tucker received no pre-op preparation” Source location 2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A urology enhanced-recovery discharge protocol was already in place, and the discharge process had been reviewed.
Verbatim wording from the response “(7) There is no coherent discharge planning protocol in place for enhanced recovery procedures in respect of urology patients” Source location 2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There was no transfer delay caused by ambulance-service communication; extrication difficulties and clinical deterioration caused the on-scene delay.
Verbatim wording from the response “(6) Eastbourne DGH’s system for recalling patients to the Urology Ward following discharge, if they need to go by ambulance, is flawed.” Source location 2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Senior clinical input remained available through an experienced robotic fellow and the urology consultant of the week during the responsible consultant’s leave.
Verbatim wording from the response “(2) The urology consultant was away during his admission and he had no senior input.” Source location 2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations