3 Jun 2025 Anthony Haydn WOOD · Prevention of Future Deaths report South London
View report summary
Concerns raised 3 Lack of crash mats at the side of the bed View source Failure to provide two staff members when preparing patients to be washed and changed View source Failure to keep the bed rail up when a patient is attended by a lone HCA View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Anthony Haydn WOOD · 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
Anthony Haydn WOOD was admitted to St. Helier Hospital and fell from his bed while being prepared to be washed and changed on 22 September 2024. He sustained intracranial injuries and died in hospital on 26 September 2024; concerns included the absence of crash mats, the bed-rail being lowered, and the patient being attended by one staff member despite identified fall risk and a need for two staff members.
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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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of crash mats at the side of the bed
Wider context from the report “(1) the patient was identified as at high risk of a fall
(2) he was deemed to be severely frail (and hence at corresponding risk, if a fall were to occur)
(3) there were no crash mats at the side of his bed
(4) it was known that the patient had a propensity to push staff when being changed
(5) the bed-rail was not up when the patient was attended by a HCA acting alone
(6) that HCA was unable, on his own, to hold on to the patient, in order to prevent him from falling out of bed
(7) the patient should have had the assistance of two members of staff, and not just one, when being prepared to be washed and changed
All of these matters are recorded in the Trust's own Datix report.
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide two staff members when preparing patients to be washed and changed
Wider context from the report “(1) the patient was identified as at high risk of a fall
(2) he was deemed to be severely frail (and hence at corresponding risk, if a fall were to occur)
(3) there were no crash mats at the side of his bed
(4) it was known that the patient had a propensity to push staff when being changed
(5) the bed-rail was not up when the patient was attended by a HCA acting alone
(6) that HCA was unable, on his own, to hold on to the patient, in order to prevent him from falling out of bed
(7) the patient should have had the assistance of two members of staff, and not just one, when being prepared to be washed and changed
All of these matters are recorded in the Trust's own Datix report.
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep the bed rail up when a patient is attended by a lone HCA
Wider context from the report “(1) the patient was identified as at high risk of a fall
(2) he was deemed to be severely frail (and hence at corresponding risk, if a fall were to occur)
(3) there were no crash mats at the side of his bed
(4) it was known that the patient had a propensity to push staff when being changed
(5) the bed-rail was not up when the patient was attended by a HCA acting alone
(6) that HCA was unable, on his own, to hold on to the patient, in order to prevent him from falling out of bed
(7) the patient should have had the assistance of two members of staff, and not just one, when being prepared to be washed and changed
All of these matters are recorded in the Trust's own Datix report.
” Open source report
23 May 2019 Sasha Sabrina FORSTER · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 6 Risk of using prescribed Propranolol for overdose View source Failure to agree and update a common action plan for revoked s.17 leave View source Failure to collect and return patients to the ward when s.17 leave is revoked View source Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol View source Failure to finalise the formal revocation of s.17 leave View source Lack of shared awareness of powers and responsibilities when s.17 leave is revoked View source See 3 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.
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AI-generated summary
Sasha Sabrina FORSTER · 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
Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.
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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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of using prescribed Propranolol for overdose
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it .
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to agree and update a common action plan for revoked s.17 leave
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked, or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances .
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to collect and return patients to the ward when s.17 leave is revoked
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked , was that they did not have the resources to allow them to do this , despite it being their legal responsibility so to do .
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked , placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, Sasha’s mother was given to believe that it would be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it.
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise the formal revocation of s.17 leave
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked, was that they did not have the resources to allow them to do this, despite it being their legal responsibility so to do.
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised , Sasha’s mother was given to believe that it would be , and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of shared awareness of powers and responsibilities when s.17 leave is revoked
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked , or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances.
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” Open source report
15 May 2018 Doris Mary Ridgwell · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Delays in authorising abnormal results onto the Clinical Manager system View source Omission of blood test results from discharge summaries View source Insufficiently clear procedures for telephoning abnormal coagulation results View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Doris Mary Ridgwell · 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
Doris Mary Ridgwell was admitted to hospital with knee swelling and pain, with an INR of 8.1 that was not successfully communicated to the ward or acted upon before her discharge. She was later admitted with a large subdural haematoma and intraventricular bleed, and the inquest determined that she died as a consequence of over-anticoagulation. Concerns included unclear procedures for communicating abnormal coagulation results, delays in making results available to healthcare professionals, and discharge summaries that did not include blood test results.
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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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in authorising abnormal results onto the Clinical Manager system
Wider context from the report “Abnormal results are not authorised onto the Clinical Manager system to be viewed by Healthcare professionals by Laboratory staff until they have telephoned the results through to the ward , which can potentially cause a delay in these being available on the system ;
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of blood test results from discharge summaries
Wider context from the report “The Discharge summaries provided to GPs following discharge from Hospital do not include blood tests results , meaning a potential safeguard to check these results is missed ;
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently clear procedures for telephoning abnormal coagulation results
Wider context from the report “The Trust’s Standard Operating Procedure for Telephoning of Coagulation Results is not sufficiently clear regarding what action should be taken by staff in the Blood Sciences Department to ensure abnormal coagulation results are made known to the treating Healthcare professionals ;
- A new Standard Operating Procedure has been prepared, but having had sight of this, I do not believe this clearly outlines for Laboratory staff the steps to be taken in telephoning through abnormal Coagulation Results ;
” 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 Revise the coagulation-results procedure to require escalation, prompt Clinical Manager release, documented communication, and shift handover when urgent abnormal results cannot be promptly telephoned.
Verbatim wording from the response “The Root Cause Analysis investigation carried out following this incident identified the fact that the Trust’s Standard Operating Procedure for the telephoning of clinically urgent abnormal coagulation results was not robust enough and that the procedure required strengthening. As a result of the investigation the Standard Operating Procedure was revised to make it clear that where it is not possible to get hold of a clinician who has requested a blood result which has been deemed clinically urgent, this needs to be handed over to those working the next shift in the Blood Sciences Department so that continues attempts to contact this clinician can be made. This strengthened the process but following the concerns raised at the inquest hearing we have strengthened the process even further.” Source location 2018-0151-Response-by-Epsom-St-Helier-University-Hospital
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 Including hospital blood results in discharge summaries is not considered necessary because GPs can access those results through Telepath.
Verbatim wording from the response “The possibility of including blood results from hospitals within hospital discharge summaries was discussed with a GP representative from the local area at the Clinical Quality Review Group on 24 May 2018. They did not feel they would be able to review blood results within patient’s discharge summaries. Moreover, it is not felt that it would be appropriate to rely on GP’s to act as a potential safeguard for abnormal results. Blood results taken in hospital can be accessed by GP’s via a computerised patient management system, Telepath.” Source location 2018-0151-Response-by-Epsom-St-Helier-University-Hospital
Open published response
27 Apr 2016 Ernest Higgs · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Failure to ensure telephone clinical advice is accurately recorded and communicated in writing View source Lack of clarity about responsibility for recording visiting GPs' advice in multidisciplinary notes View source Unclear out-of-hours pathology laboratory provision for community care providers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ernest Higgs · 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
Ernest Higgs, a resident of a nursing home, was admitted to hospital after his health deteriorated and died there on 20 January 2015 from aspiration pneumonia. Concerns included unclear and poorly recorded telephone advice from a GP, uncertainty over responsibility for recording clinical advice, and conflicting information about out-of-hours pathology services that contributed to a delay in blood testing.
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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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure telephone clinical advice is accurately recorded and communicated in writing
Wider context from the report “(2) Advice given by the GP over the telephone to make Mr Higgs “nil by mouth” was not recorded and no confirmation of that advice in writing was sent by email . There did not appear to be a safe system in place to ensure telephone advice was accurately sent and received.
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about responsibility for recording visiting GPs' advice in multidisciplinary notes
Wider context from the report “(1) It was clear from the evidence that confusion arose over what advice had been given by the GP on the 15th January 2015. No record was made in the multi-disciplinary notes by the GP of her attendance at Milner House. Care UK the parent company of Milner House offered to liaise with their local surgeries to ensure the records were made by visiting GPs. However it appears that the BMA advice to GPs “Quality First Managing Workload To Deliver Safer Patient Care” advises against GPs filling in multi-disciplinary notes. There was no clarity about whose responsibility it was to fill in the notes.
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear out-of-hours pathology laboratory provision for community care providers
Wider context from the report “(3) There was conflicting evidence from Care UK and Epsom hospital about OOH provision at the hospital pathology laboratory for community care providers resulting in a significant delay to a diagnostic blood test being undertaken.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include urgent out-of-hours pathology access guidance in the newsletter sent to GPs in the Trust’s catchment area.
Verbatim wording from the response “Whilst all GPs should be aware of the twenty four hour access to the Trust’s pathology department, seven days a week, as a reminder, we are including the following statement within the newsletter sent to the GPs within the Trust’s catchment area, due to be sent out later this month.” Source location 2016-0181-Response-by-Epsom-and-St-Helier-University-Hospital-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 Send letters to the three local CCGs requesting dissemination of out-of-hours pathology access information to registered care homes.
Verbatim wording from the response “We will also be sending a letter to each of our three local CCGs requesting that this information is passed on to all registered care homes in their area.” Source location 2016-0181-Response-by-Epsom-and-St-Helier-University-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust had 24-hour pathology access and an established out-of-hours process, contrary to the concern about unavailable provision.
Verbatim wording from the response “In relation to the Coroner’s third concern the Trust confirms that there is twenty four hour access to the Trust’s pathology department, seven days a week and that the staff at Milner House would have been able to access the out of hours pathology department at Epsom Hospital either via drop off in A and E or by contacting the biochemist on call at any time between 14 and 19 January 2015. The blood results would have been processed within a matter of hours of them being delivered and the results would have been given to whoever was listed as the contact on the request slip which must be provided when the bloods are left with the pathology department.” Source location 2016-0181-Response-by-Epsom-and-St-Helier-University-Hospital-NHS-Trust
Open published response
2 Mar 2016 Christ Morrison · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure to ensure staff are skilled and equipped to perform an emergency tracheostomy after failed tube replacement View source Lack of clarity about necessary training levels for staff changing children's tracheostomy tubes at home View source Failure to provide medical presence during children's tracheostomy tube changes at home View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Christ Morrison · 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
Christ Morrison was born at 24 weeks gestation in 2005 and developed chronic lung disease requiring a tracheostomy. On 10 September 2014, the tracheostomy tube was removed and could not be replaced; despite resuscitation and transfer to a specialist centre, he died on 17 October 2014. The principal concerns were the training required for staff changing children's tracheostomy tubes at home, the absence of medical presence, and the lack of provision for an emergency tracheostomy when replacement failed.
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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff are skilled and equipped to perform an emergency tracheostomy after failed tube replacement
Wider context from the report “It was not clear what level of training was necessary for the staff changing tracheostomy tubes of children at home. The mother was very concerned that this should be performed by a nurse without medical presence.
It was also submitted at inquest that in the event of failure to replace a tube, the health care professional should be skilled and equipped to perform a new emergency tracheostomy . This was not the position in this case.
Whilst processes for changing tubes has changed since this inquest, with two staff as a minimum now being required to be present, the court was informed that the Epsom and St Helier Paediatric Tracheostomy Policy complied with processes complied with other Trusts. But it makes clear that failure to reintubate requires emergency transfer to A&E rather than emergency tracheostomy and does not require a medical presence.
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about necessary training levels for staff changing children's tracheostomy tubes at home
Wider context from the report “It was not clear what level of training was necessary for the staff changing tracheostomy tubes of children at home. The mother was very concerned that this should be performed by a nurse without medical presence.
It was also submitted at inquest that in the event of failure to replace a tube, the health care professional should be skilled and equipped to perform a new emergency tracheostomy. This was not the position in this case.
Whilst processes for changing tubes has changed since this inquest, with two staff as a minimum now being required to be present, the court was informed that the Epsom and St Helier Paediatric Tracheostomy Policy complied with processes complied with other Trusts. But it makes clear that failure to reintubate requires emergency transfer to A&E rather than emergency tracheostomy and does not require a medical presence.
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide medical presence during children's tracheostomy tube changes at home
Wider context from the report “It was not clear what level of training was necessary for the staff changing tracheostomy tubes of children at home. The mother was very concerned that this should be performed by a nurse without medical presence.
It was also submitted at inquest that in the event of failure to replace a tube, the health care professional should be skilled and equipped to perform a new emergency tracheostomy. This was not the position in this case.
Whilst processes for changing tubes has changed since this inquest, with two staff as a minimum now being required to be present, the court was informed that the Epsom and St Helier Paediatric Tracheostomy Policy complied with processes complied with other Trusts. But it makes clear that failure to reintubate requires emergency transfer to A&E rather than emergency tracheostomy and does not require a medical presence.
” 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 Require two competent carers for planned paediatric tracheostomy tube changes, with two community nurses attending when families request community support.
Verbatim wording from the response “For all planned tube changes there must now be two competent carers present.” Source location 2016-0084-Response-by-Epsom-and-St-Helier-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 Provide mandatory annual paediatric life-support training, completed competencies, and yearly simulated tracheostomy training updates for community staff.
Verbatim wording from the response “The level of training for staff carrying out or assisting a parent with routine tube changes would be as above for the parents/carers with the addition of:” Source location 2016-0084-Response-by-Epsom-and-St-Helier-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 Update the paediatric tracheostomy policy to provide clearer signposting to the NTSP emergency management algorithm and require Emergency Department review after life-threatening events.
Verbatim wording from the response “However, as a result of the inquest and the Report, the Trust has reviewed its procedures within the policy and has strengthened this section which now signposts staff further to follow the NTSP (2014) algorithm for Emergency Paediatric Tracheotomy Management (copy enclosed). This is now clearer in the body of the policy.⁴” Source location 2016-0084-Response-by-Epsom-and-St-Helier-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 Nurses cannot be trained to perform emergency tracheostomies because the procedure is high-risk and outside registered children’s nurses’ competence.
Verbatim wording from the response “Emergency tracheostomy, even performed by two competent, skilled, specialist surgeons, in ideal operating theatre facilities with all the relevant lighting, instruments and anaesthetic support is a high-risk, invasive procedure with an associated mortality, 2-3 times higher in children than adults. (Alladi A, Rao S, et al 2004).” Source location 2016-0084-Response-by-Epsom-and-St-Helier-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 Medical presence at home for routine tracheostomy changes is not practicable because medical teams cannot reliably provide home visits.
Verbatim wording from the response “Families are also offered the opportunity to have routine tube changes carried out in the clinical setting / hospital where medical staff are available. This option is sometimes a mandatory arrangement in the event of a child with known difficulty or high risk of complications at tube changes. With regard to medical presence at home, this is not practical due to the availability of the medical team to carry out home visits and also that carers must feel confident in performing emergency tube changes at home / school when there are no professional available.” Source location 2016-0084-Response-by-Epsom-and-St-Helier-NHS-Trust
Open published response
30 Mar 2015 Kenneth John WILLIAMS · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Failure to notify the respiratory team about patients with inserted chest drains View source Failure to train medical staff to access historical imaging View source Failure of subsequent medical teams to re-review previous medical history, historical imaging and medications after A&E transfer View source Failure to seek respiratory consultant opinion before chest drain insertion View source Failure to consider previous radiology, medical history and medication before invasive procedures View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kenneth John WILLIAMS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kenneth John Williams was admitted with shortness of breath and was diagnosed with tension pneumothorax, leading to insertion of a chest drain. The report states that the diagnosis was incorrect, the drain ruptured a pulmonary bulla and caused bleeding, and concerns included reviewing previous imaging and medical history and involving the respiratory team before and after chest-drain insertion.
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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the respiratory team about patients with inserted chest drains
Wider context from the report “3. Action is required to ensure the respiratory team is made aware of all patients who have had a chest drain inserted .
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to train medical staff to access historical imaging
Wider context from the report “5. Action is required to ensure all medical staff are trained how to access historical imaging .
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of subsequent medical teams to re-review previous medical history, historical imaging and medications after A&E transfer
Wider context from the report “4. Action is required to ensure patents previous medical history, historical imaging and medications are always reviewed anew by any subsequent medical team receiving the patient from A&E .
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek respiratory consultant opinion before chest drain insertion
Wider context from the report “2. Action is required to ensure respiratory consultants opinion is sought where possible before inserting a chest drain .
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider previous radiology, medical history and medication before invasive procedures
Wider context from the report “1. Action is required to ensure that previous radiology, patients medical history and medication is always considered before a chest drain insertion or any invasive procedure is undertaken .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement adult transfer and four-hour-plan checklists requiring handover teams to document medications and consider historical radiology.
Verbatim wording from the response “4. Action is required to ensure a patient’s previous medical history, historical imaging and medications are always reviewed anew by any subsequent medical team receiving the patient from Accident and Emergency.” Source location 2015-0135-Response-by-Epsom-and-St-Helier-University-Hospitals-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 Use an introduced medical proforma requiring clerking staff to record patients’ medical history and medication.
Verbatim wording from the response “a. Medical Proforma” Source location 2015-0135-Response-by-Epsom-and-St-Helier-University-Hospitals-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 Use the upgraded Sectra PACS system, with date-of-birth and hospital-number searching, to improve access and accuracy when locating historical radiology.
Verbatim wording from the response “c. Upgrade of the trust’s radiology computer system (PACS)” Source location 2015-0135-Response-by-Epsom-and-St-Helier-University-Hospitals-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 Deliver chest-drain training that reinforces reviewing historical radiology, medical history and medication and involving the respiratory team in patient care.
Verbatim wording from the response “b. Training” Source location 2015-0135-Response-by-Epsom-and-St-Helier-University-Hospitals-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 Cascade instructions requiring respiratory-team involvement and notification for every patient who has had a chest drain inserted.
Verbatim wording from the response “3. Action is required to ensure the respiratory team is made aware of all patients who have had a chest drain inserted.” Source location 2015-0135-Response-by-Epsom-and-St-Helier-University-Hospitals-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 Use a spontaneous-pneumothorax pathway requiring respiratory-team discussion before chest-drain insertion.
Verbatim wording from the response “2. Action is required to ensure a respiratory consultants opinion is sought where possible before inserting a chest drain.” Source location 2015-0135-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Open published response
14 Oct 2013 Frederick Davidson · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 9 Delays in medical treatment following pneumothorax View source Failure to recognise pneumothorax on X-rays View source Inadequate recording of nasogastric tube placement View source Feeding via nasogastric tube before completion of full checks View source Failure to record nasogastric tube feeding authorisation View source Inappropriate use of nasogastric tubes for patients with advanced dementia and seizures View source Unexplained gaps in clinical notes View source Delays in forwarding and receiving X-ray reports from radiology View source Breakdown in communication between junior doctors and consultants View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Frederick Davidson · 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
Frederick Davidson was admitted to Epsom General Hospital with aspiration pneumonia after recurrent seizures and later died following a pneumothorax caused by an unnoticed and incorrectly placed nasogastric tube. Concerns included inadequate documentation and communication, the use and checking of the tube, delayed recognition and treatment of the pneumothorax, and delays in radiology reporting.
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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in medical treatment following pneumothorax
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment .
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise pneumothorax on X-rays
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of nasogastric tube placement
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Feeding via nasogastric tube before completion of full checks
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record nasogastric tube feeding authorisation
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate use of nasogastric tubes for patients with advanced dementia and seizures
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unexplained gaps in clinical notes
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in forwarding and receiving X-ray reports from radiology
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” 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 Epsom and St Helier University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Breakdown in communication between junior doctors and consultants
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations