Recipient

Family of Gillian McKinlay

First report 12 Feb 2021•Latest report 12 Feb 2021

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

12 Feb2021
Lancashire and Blackburn with Darwen
Concerns raised9
1. Inadequacy of the action plan for reducing delays in NG tube insertion and decompression
2. Failure to check medical records completed by junior doctors
3. Lack of audit of the effectiveness of safety measures
1. Failure of the serious incident investigation to identify why NG tube placement failures were not escalated or referred back to requesting teams
2. Failure of nursing escalation when an NG tube cannot be sited and clinical review has not occurred
3. Failure to identify and document the staff member, records, and actions relevant to an arterial blood gas during the investigation
4. Failure to ensure factual accuracy and evidential support for reported EWS escalation
5. Lack of clear allocation of overall clinical responsibility for patients remaining in the Accident and Emergency Department
6. Failure to complete or appropriately refer mandated clinical reviews triggered by EWS scores
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

Gillian McKinlay · 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

Gillian McKinlay, aged 68, was admitted to Royal Blackburn Hospital on 23 April 2018 with a provisional diagnosis of small bowel obstruction. A nasogastric tube requested by clinicians was not sited before her death four hours later, and the Coroner considered this contributed to the death. Concerns included unclear responsibility for patients in the Accident and Emergency Department, failure to undertake or escalate a clinically indicated review, and inadequacies in the Trust's investigation and subsequent measures.

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 Gillian McKinlay; that does not assign responsibility.
PFD Monitor interpretation
Inadequacy of the action plan for reducing delays in NG tube insertion and decompression
Wider context from the report
“1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care. 2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams. 3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy. 4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken: a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate; b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred; c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken; d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect; e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked; f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect. ”
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 Gillian McKinlay; that does not assign responsibility.
PFD Monitor interpretation
Failure to check medical records completed by junior doctors
Wider context from the report
“1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care. 2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams. 3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy. 4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken: a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate; b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred; c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken; d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect; e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked; f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect. ”
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 Gillian McKinlay; that does not assign responsibility.
PFD Monitor interpretation
Lack of audit of the effectiveness of safety measures
Wider context from the report
“1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care. 2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams. 3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy. 4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken: a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate; b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred; c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken; d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect; e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked; f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect. ”
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 Gillian McKinlay; that does not assign responsibility.
PFD Monitor interpretation
Failure of the serious incident investigation to identify why NG tube placement failures were not escalated or referred back to requesting teams
Wider context from the report
“1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care. 2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams. 3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy. 4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken: a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate; b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred; c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken; d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect; e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked; f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect. ”
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 Gillian McKinlay; that does not assign responsibility.
PFD Monitor interpretation
Failure of nursing escalation when an NG tube cannot be sited and clinical review has not occurred
Wider context from the report
“1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care. 2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams. 3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy. 4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken: a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate; b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred; c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken; d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect; e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked; f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect. ”
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 Gillian McKinlay; that does not assign responsibility.
PFD Monitor interpretation
Failure to identify and document the staff member, records, and actions relevant to an arterial blood gas during the investigation
Wider context from the report
“1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care. 2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams. 3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy. 4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken: a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate; b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred; c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken; d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect; e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked; f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect. ”
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 Gillian McKinlay; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure factual accuracy and evidential support for reported EWS escalation
Wider context from the report
“1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care. 2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams. 3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy. 4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken: a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate; b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred; c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken; d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect; e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked; f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect. ”
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 Gillian McKinlay; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear allocation of overall clinical responsibility for patients remaining in the Accident and Emergency Department
Wider context from the report
“1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care. 2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams. 3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy. 4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken: a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate; b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred; c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken; d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect; e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked; f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect. ”
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 Gillian McKinlay; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete or appropriately refer mandated clinical reviews triggered by EWS scores
Wider context from the report
“1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care. 2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams. 3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy. 4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken: a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate; b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred; c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken; d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect; e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked; f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect. ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised9

Inadequacy of the action plan for reducing delays in NG tube insertion and decompression

Failure to check medical records completed by junior doctors

Lack of audit of the effectiveness of safety measures

Failure of the serious incident investigation to identify why NG tube placement failures were not escalated or referred back to requesting teams

Failure of nursing escalation when an NG tube cannot be sited and clinical review has not occurred

Failure to identify and document the staff member, records, and actions relevant to an arterial blood gas during the investigation

Failure to ensure factual accuracy and evidential support for reported EWS escalation

Lack of clear allocation of overall clinical responsibility for patients remaining in the Accident and Emergency Department

Failure to complete or appropriately refer mandated clinical reviews triggered by EWS scores