Family of Alexander Davidson

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First report 2 May 2019•Latest report 2 May 2019

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Family of Alexander Davidson linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Nottinghamshire

    AI-generated summary

    Alexander James 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

    Alexander James Davidson became suddenly unwell with abdominal pain, vomiting and diarrhoea, and died at the Queens Medical Centre on 26 February 2018 after developing an infected and necrotic pancreatic pseudocyst caused by gallstone pancreatitis. The report raised concerns about NHS 111 telephone triage for young or vulnerable patients, the clarity and transfer of triage information, testing for pancreatitis in young people, and the management of unscheduled returns to emergency departments.

    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 Family of Alexander Davidson; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in updating electronic patient records with NHS 111 triage documents

    Wider context from the report

    “(3) The NHS 111 telephone triage service provides an electronic copy of the patient triage notes to the patient’s GP within minutes of the call ending. There was a delay of 7 days in the GP surgery uploading the 111 triage document to Alex’s patient record. This prevented Alex’s GP from reviewing the triage note prior to his consultation with the patient. There is no guidance as to expected practise with regards to the timely updating of electronic patient records, and as a result delays are all too frequent. ”
    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 Family of Alexander Davidson; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients

    Wider context from the report

    “(1) The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be assisted to provide accurate information about their symptoms. ”
    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 Family of Alexander Davidson; that does not assign responsibility.

    PFD Monitor interpretation

    Variation in admission for observation of paediatric patients returning to the Emergency Department

    Wider context from the report

    “(5) Patients who make an unscheduled return to the Emergency Department within 72 hours of discharge are required to have a review undertaken by an ED Consultant, or a ST4 trainee or above in the absence of a Consultant on the ‘shop floor’: RCEM Guidance June 2016. Some hospitals will admit returning paediatric patients for observation but practise seems to vary doctor-to-doctor and across Trusts. Consideration ought to be given to a national approach. ”
    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 Family of Alexander Davidson; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage

    Wider context from the report

    “(2) The NHS Pathways algorithm for triaging vomiting and diarrhoea symptoms is unclear as patients may fail to understand what is meant by ‘soil’ or ‘coffee ground’ vomit. Consideration should be given to how this important diagnostic feature can be explored during telephone triage, especially when the patient is young and/or vulnerable. ”
    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 Family of Alexander Davidson; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of standard lipase/amylase testing for patients under 18 with relevant abdominal symptoms

    Wider context from the report

    “(4) Adults presenting to their GP or Emergency Department with abdominal symptoms receive a lipase and/or amylase blood test as part of the standard package of blood testing. The levels of each of these enzymes can be used to diagnose pancreatitis. Patients under the age of 18 years are not offered this testing as standard, on the basis that pancreatitis is rare in paediatric patients. I heard anecdotal evidence of some doctors at Kingsmill Hospital now add this test to the standard admission bloods for older teenage patients who present with non-specific abdominal symptoms but the NICE guidance (September 2018) is not explicit in this regard. I heard evidence as to the increasing prevalence of gallstone pancreatitis in young people, in line with an increase in childhood obesity. Consideration ought to be given to a national approach for lipase/amylase testing in young people with relevant symptoms. ”
    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

Data last updated 7 September 2026