30 Mar 2026 John Albert TARRANT · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 4 Poor understanding of anticoagulation risks and reversal urgency View source Failure to ensure accurate falls risk assessment data and outcomes View source Lack of assessment and auditing of falls risk assessment accuracy View source Failure of the post-falls proforma to prompt consideration of anticoagulation reversal and urgency View source See 1 more concern
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
John Albert TARRANT · 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
John Albert Tarrant, aged 84, died at Wexham Park Hospital after an unwitnessed fall while an inpatient on 29 April 2025, sustaining a brain bleed that later became unsurvivable. The principal concerns were inaccurate falls risk assessments and insufficient awareness or prompting regarding the urgency of anticoagulation reversal after a fall.
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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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor understanding of anticoagulation risks and reversal urgency
Wider context from the report “2. Anti coagulation risk awareness
The doctor who reviewed the CT results and neurosurgery advice after Mr Tarrant fell did not appreciate the urgency of the situation. I found in this inquest that due to timing issues this was not likely to have affected the outcome for Mr Tarrant.
I heard from the consultant witness that the risks of anticoagulation are poorly understood.
The post falls proforma was reviewed in court and, whilst it asked whether the patient was on anticoagulation medication, it did not provide a prompt about this during the post fall medical planning section. This led to a concern that the importance of considering and administering an anticoagulation reversal medication and the urgency of such a need may be underappreciated.
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate falls risk assessment data and outcomes
Wider context from the report “1. Falls risk assessments.
Only 2 falls risk assessments were carried out after Mr Tarrant arrived at the hospital. Both falls risk assessments used the Hester Davis scoring system but both had carried out based on incorrect data. The falls risk assessments both resulted in a low-risk outcome which was not correct. Mr Tarrant should have been graded as a moderate risk even prior to his fall.
Some of the data entered into the risk assessment tool was objectively wrong. For example in the risk assessment carried out hours after his fall it stated that he had not fallen before.
I heard that the Trust did not have a way of assessing and auditing the accuracy of these risk assessments.
Whilst I found that the errors in this inquest did not contribute to Mr Tarrant’s death incorrect risk assessments can lead to inadequate falls mitigation measures being put in place and incorrect information being provided to 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of assessment and auditing of falls risk assessment accuracy
Wider context from the report “1. Falls risk assessments.
Only 2 falls risk assessments were carried out after Mr Tarrant arrived at the hospital. Both falls risk assessments used the Hester Davis scoring system but both had carried out based on incorrect data. The falls risk assessments both resulted in a low-risk outcome which was not correct. Mr Tarrant should have been graded as a moderate risk even prior to his fall.
Some of the data entered into the risk assessment tool was objectively wrong. For example in the risk assessment carried out hours after his fall it stated that he had not fallen before.
I heard that the Trust did not have a way of assessing and auditing the accuracy of these risk assessments.
Whilst I found that the errors in this inquest did not contribute to Mr Tarrant’s death incorrect risk assessments can lead to inadequate falls mitigation measures being put in place and incorrect information being provided to 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the post-falls proforma to prompt consideration of anticoagulation reversal and urgency
Wider context from the report “2. Anti coagulation risk awareness
The doctor who reviewed the CT results and neurosurgery advice after Mr Tarrant fell did not appreciate the urgency of the situation. I found in this inquest that due to timing issues this was not likely to have affected the outcome for Mr Tarrant.
I heard from the consultant witness that the risks of anticoagulation are poorly understood.
The post falls proforma was reviewed in court and, whilst it asked whether the patient was on anticoagulation medication, it did not provide a prompt about this during the post fall medical planning section. This led to a concern that the importance of considering and administering an anticoagulation reversal medication and the urgency of such a need may be underappreciated.
” Open source report
27 Nov 2025 June Violet FINDLAY · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 5 Failure to correctly utilise care planning tools for malnutrition risks View source Failure of records auditing to identify repeated omissions of required information View source Failure to follow dietician advice and care plans View source Failure to properly recognise patients’ risk of malnutrition View source Failure to monitor and record malnutrition-risk interventions View source See 2 more concerns
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. 8
Action
Develop and deliver updated nutrition and hydration training covering documentation, mealtimes, trays, diets and supplements, with area-level compliance monitoring.
Stated plannedThe respondent said that this action was planned when they made their response on 3 December 2025. View source
Action
Implement a weight-loss flag that triggers a multidisciplinary swarm huddle and individualised care planning, with compliance monitoring.
Stated plannedThe respondent said that this action was planned when they made their response on 3 December 2025. View source
Action
Deliver refresher training on nutritional risk assessment and Epic care planning through the Harm Free Care programme, with compliance monitoring.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 December 2025. View source
Action
Develop a standard operating procedure for identifying, managing and escalating significant weight loss.
Stated plannedThe respondent said that this action was planned when they made their response on 3 December 2025. View source
Action
Run the Harm Free Care audit programme to monitor food-chart completion, nutritional care and significant-weight-loss escalation.
Stated completedThe respondent said that this action was complete when they made their response on 3 December 2025. View source
Action
Amend Epic care flowsheets to capture food and fluid intake in greater detail and disseminate supporting safety communications.
Stated completedThe respondent said that this action was complete when they made their response on 3 December 2025. View source
Action
Require Divisional Directors of Nursing to provide assurance that patients’ nutrition and hydration needs are assessed, met and accurately recorded.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 December 2025. View source
Action
Escalate patients with significant weight loss to the Ward Matron for a documented multidisciplinary swarm review including dietitians.
Stated plannedThe respondent said that this action was planned when they made their response on 3 December 2025. View source See 5 more actions
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AI-generated summary
June Violet FINDLAY · 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
June Violet Findlay fell at home on 23 October 2024, fracturing her hip and wrist, and later died at Thames Hospice on 11 December 2024 after her health deteriorated. Concerns included substantial weight loss and sub-optimal management, monitoring, recording, and auditing of the risk of malnutrition during her hospital admission.
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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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly utilise care planning tools for malnutrition risks
Wider context from the report “During the course of Mrs Findlay’s 9-10 days at Frimley Park Hospital she lost at least 5.3kg from an already low weight. She had been assessed as being at high risk of malnutrition shortly after her admission. The care planning records were inconsistent about the interventions required and the level of risk. The record keeping of the actual interventions used on a daily basis to address this risk were absent or largely incomplete and I found that the ward staff did not properly follow the dietician’s advice or the care plans.
I am concerned that ward staff are not:
1. Properly recognising the risk of malnutrition to patients, even after completing the MUST2 assessments;
2. Correctly utilising care planning tools to address the risks of malnutrition ;
3. Properly monitoring and recording the interventions undertaken to address the risk. This places patients at risk due to unclear information and also means that the hospital cannot learn from mistakes or pick up near misses.
No evidence was forthcoming from the Trust at inquest that these shortcomings at Frimley Park Hospital had been acted upon despite the court hearing that 100% of the ward staff had received MUST training and records were audited on a monthly basis. This gives rise to a further concern:
4. The auditing of records does not seem to have identified the repeated failures to record required information.
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of records auditing to identify repeated omissions of required information
Wider context from the report “During the course of Mrs Findlay’s 9-10 days at Frimley Park Hospital she lost at least 5.3kg from an already low weight. She had been assessed as being at high risk of malnutrition shortly after her admission. The care planning records were inconsistent about the interventions required and the level of risk. The record keeping of the actual interventions used on a daily basis to address this risk were absent or largely incomplete and I found that the ward staff did not properly follow the dietician’s advice or the care plans.
I am concerned that ward staff are not:
1. Properly recognising the risk of malnutrition to patients, even after completing the MUST2 assessments;
2. Correctly utilising care planning tools to address the risks of malnutrition;
3. Properly monitoring and recording the interventions undertaken to address the risk. This places patients at risk due to unclear information and also means that the hospital cannot learn from mistakes or pick up near misses.
No evidence was forthcoming from the Trust at inquest that these shortcomings at Frimley Park Hospital had been acted upon despite the court hearing that 100% of the ward staff had received MUST training and records were audited on a monthly basis. This gives rise to a further concern:
4. The auditing of records does not seem to have identified the repeated failures to record required information.
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow dietician advice and care plans
Wider context from the report “During the course of Mrs Findlay’s 9-10 days at Frimley Park Hospital she lost at least 5.3kg from an already low weight. She had been assessed as being at high risk of malnutrition shortly after her admission. The care planning records were inconsistent about the interventions required and the level of risk. The record keeping of the actual interventions used on a daily basis to address this risk were absent or largely incomplete and I found that the ward staff did not properly follow the dietician’s advice or the care plans.
I am concerned that ward staff are not:
1. Properly recognising the risk of malnutrition to patients, even after completing the MUST2 assessments;
2. Correctly utilising care planning tools to address the risks of malnutrition;
3. Properly monitoring and recording the interventions undertaken to address the risk. This places patients at risk due to unclear information and also means that the hospital cannot learn from mistakes or pick up near misses.
No evidence was forthcoming from the Trust at inquest that these shortcomings at Frimley Park Hospital had been acted upon despite the court hearing that 100% of the ward staff had received MUST training and records were audited on a monthly basis. This gives rise to a further concern:
4. The auditing of records does not seem to have identified the repeated failures to record required information.
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly recognise patients’ risk of malnutrition
Wider context from the report “During the course of Mrs Findlay’s 9-10 days at Frimley Park Hospital she lost at least 5.3kg from an already low weight. She had been assessed as being at high risk of malnutrition shortly after her admission. The care planning records were inconsistent about the interventions required and the level of risk. The record keeping of the actual interventions used on a daily basis to address this risk were absent or largely incomplete and I found that the ward staff did not properly follow the dietician’s advice or the care plans.
I am concerned that ward staff are not:
1. Properly recognising the risk of malnutrition to patients, even after completing the MUST2 assessments ;
2. Correctly utilising care planning tools to address the risks of malnutrition;
3. Properly monitoring and recording the interventions undertaken to address the risk. This places patients at risk due to unclear information and also means that the hospital cannot learn from mistakes or pick up near misses.
No evidence was forthcoming from the Trust at inquest that these shortcomings at Frimley Park Hospital had been acted upon despite the court hearing that 100% of the ward staff had received MUST training and records were audited on a monthly basis. This gives rise to a further concern:
4. The auditing of records does not seem to have identified the repeated failures to record required information.
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor and record malnutrition-risk interventions
Wider context from the report “During the course of Mrs Findlay’s 9-10 days at Frimley Park Hospital she lost at least 5.3kg from an already low weight. She had been assessed as being at high risk of malnutrition shortly after her admission. The care planning records were inconsistent about the interventions required and the level of risk. The record keeping of the actual interventions used on a daily basis to address this risk were absent or largely incomplete and I found that the ward staff did not properly follow the dietician’s advice or the care plans.
I am concerned that ward staff are not:
1. Properly recognising the risk of malnutrition to patients, even after completing the MUST2 assessments;
2. Correctly utilising care planning tools to address the risks of malnutrition;
3. Properly monitoring and recording the interventions undertaken to address the risk. This places patients at risk due to unclear information and also means that the hospital cannot learn from mistakes or pick up near misses.
No evidence was forthcoming from the Trust at inquest that these shortcomings at Frimley Park Hospital had been acted upon despite the court hearing that 100% of the ward staff had received MUST training and records were audited on a monthly basis. This gives rise to a further concern:
4. The auditing of records does not seem to have identified the repeated failures to record required information.
” 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 Develop and deliver updated nutrition and hydration training covering documentation, mealtimes, trays, diets and supplements, with area-level compliance monitoring.
Verbatim wording from the response “3. A thorough review/map of all the education programmes/study days that are provided for both registered nurses and healthcare support workers is underway. The aim is to ensure that the training we are providing all staff is fit for purpose. The new education programme will address the following key concerns: documentation to ensure accurate recording of food consumption, protected mealtimes, tray colours and ensuring the patient receives the correct diet for example soft, and when supplements should be given. All staff will be given the updated training and compliance for each clinical area will be monitored by the NHSSG.” Source location Response from Frimley Health NHS Foundation 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 Implement a weight-loss flag that triggers a multidisciplinary swarm huddle and individualised care planning, with compliance monitoring.
Verbatim wording from the response “1. Implement a new system to flag patients with a concerning weight loss which triggers a swarm huddle. A swarm huddle is designed to start as soon as possible after a patient safety incident occurs so in this case significant weight loss is identified. The purpose of the swarm-based huddle is to identify learning from patient safety incidents; this is in line with the National Patient Safety Framework (PSIRF). Immediately after an incident this identified the multidisciplinary staff ‘swarm’ to the ward to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning. It will be expected that the swarm is attended by the Ward Matron and a member of the Patient Safety Team.” Source location Response from Frimley Health NHS Foundation 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 refresher training on nutritional risk assessment and Epic care planning through the Harm Free Care programme, with compliance monitoring.
Verbatim wording from the response “Harm Free Care - A trust campaign was launched in July 2025 to support a focus on 4 key areas relating to improving patient safety. This included improving nutritional care for patients to ensure they are assessed for nutritional status and risk of malnutrition using the malnutrition universal screening tool (MUST). If they are malnourished or at risk, interventions will be implemented to ensure that their status is improved as much as possible.” Source location Response from Frimley Health NHS Foundation 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 Develop a standard operating procedure for identifying, managing and escalating significant weight loss.
Verbatim wording from the response “2. Develop a Standard Operating Procedure (SOP) for the identification, management and escalation of weight loss.” Source location Response from Frimley Health NHS Foundation 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 Run the Harm Free Care audit programme to monitor food-chart completion, nutritional care and significant-weight-loss escalation.
Verbatim wording from the response “Audit – There will be an altered focus on the audit to provide assurance that patients are adequately fed according to their need and that any significant weight loss is appropriately escalated to the Ward Matron to ensure that high risk patients are highlighted and appropriate action is taken and documented in line with the new weight loss SOP.” Source location Response from Frimley Health NHS Foundation 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 Epic care flowsheets to capture food and fluid intake in greater detail and disseminate supporting safety communications.
Verbatim wording from the response “5. Review of how Food & Fluid intake can be documented on Epic (Trust Electronic Patient Record) - the daily care flowsheets have been amended to allow for nutritional intake to be documented in more detail. Safety message and electronic patient record (EPR) bulletins have gone out to clinical staff.” Source location Response from Frimley Health NHS Foundation 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 Divisional Directors of Nursing to provide assurance that patients’ nutrition and hydration needs are assessed, met and accurately recorded.
Verbatim wording from the response “4. Divisional Directors of Nursing (DDONS) within the new Divisional Structure will be required to provide assurance to the Chief of Nursing and Midwifery that the nutrition and hydration needs of patients cared for in their division are being assessed and consistently met and accurately recorded.” Source location Response from Frimley Health NHS Foundation 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 Escalate patients with significant weight loss to the Ward Matron for a documented multidisciplinary swarm review including dietitians.
Verbatim wording from the response “3. All patients who are identified with significant weight loss in line with the SOP will be escalated to the Ward Matron who will ensure that a full swarm review including dieticians is undertaken and appropriate actions are taken and clearly documented.” Source location Response from Frimley Health NHS Foundation Trust
Open published response
7 Jul 2025 Patrick Anthony COFFEY · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 2 Failure to properly record patient repositioning View source Failure to reposition patients every 2-4 hours 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
Patrick Anthony COFFEY · 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
Patrick Anthony Coffey fell at home, fractured multiple ribs, remained on the floor for about 17 hours, developed a chest infection and subsequently deteriorated in hospital. The report identified concerns that his pain was not always effectively controlled and that he was probably not repositioned every 2–4 hours as required, with gaps of up to 27 hours in the records; it stated that this posed a risk of future deaths in people with chest infections or at risk of pressure damage.
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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly record patient repositioning
Wider context from the report “I heard evidence that it was important that Mr Coffey spent most of his time in a seated position rather than lying down. This was to assist with his ability to breathe more deeply and cough more effectively; both of which are of importance when treating chest infections especially in the context of a patient with rib fractures.
The nursing witness for the trust confirmed that Mr Coffey should have been repositioned every 2-4 hours. It had been identified by the hospital during random monthly audits that this was either not being done or not being properly recorded.
Frimley Trust, after the inquest concluded, provided confirmation of when Mr Coffey’s position was recorded during his stay. These reveal that on certain days almost no information is recorded and on other days it is possible to know his position on a 2-4 hourly basis.
Of particular note is the following:
1. There is no record of his position from 16.39 on the 15/9/2024 to 06.51 on the 16/09/24,
2. The only record between 19.11 on the 16/9/24 and 04.18 on the 18/9/24 is one entry at 06.23 on the 17/9/24
3. The only record between 22.26 on the 18/9/24 and 01.51 on the 20/9/24 is one entry at 10.34 on the 19/9/24
4. There are only 2 entries for the 22/9/24 at 06.06 & 22.11
5. The entries for the 24/9/24 cease at 14.08 and they do not restart until 12.24 on the 25/9/24
6. The last entry on the 25/9/24 is at 14.35 and the next entry is not until 17.59 on the 26/9/24
7. The final entry on the 26/9/24 is at 20.54 and the first entry on the 27/9/24 is at 10.03.
These records therefore have gaps of up to 27 hours.
In addition the vast majority of records that do exist do not reveal whether Mr Coffey was actually repositioned as only one position is recorded. It is only on about 7 or 8 occasions that a repositioning has been recorded.
The medical records from the hospital do not show repositioning every 2-4 hours and I found that Mr Coffey was probably not repositioned as required. In the particular circumstances of Mr Coffey this did not contribute to his death lack of repositioning does give rise to a risk of future deaths of those suffering from chest infections or, indeed, those particularly at risk of pressure damage.
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reposition patients every 2-4 hours
Wider context from the report “I heard evidence that it was important that Mr Coffey spent most of his time in a seated position rather than lying down. This was to assist with his ability to breathe more deeply and cough more effectively; both of which are of importance when treating chest infections especially in the context of a patient with rib fractures.
The nursing witness for the trust confirmed that Mr Coffey should have been repositioned every 2-4 hours. It had been identified by the hospital during random monthly audits that this was either not being done or not being properly recorded.
Frimley Trust, after the inquest concluded, provided confirmation of when Mr Coffey’s position was recorded during his stay. These reveal that on certain days almost no information is recorded and on other days it is possible to know his position on a 2-4 hourly basis.
Of particular note is the following:
1. There is no record of his position from 16.39 on the 15/9/2024 to 06.51 on the 16/09/24,
2. The only record between 19.11 on the 16/9/24 and 04.18 on the 18/9/24 is one entry at 06.23 on the 17/9/24
3. The only record between 22.26 on the 18/9/24 and 01.51 on the 20/9/24 is one entry at 10.34 on the 19/9/24
4. There are only 2 entries for the 22/9/24 at 06.06 & 22.11
5. The entries for the 24/9/24 cease at 14.08 and they do not restart until 12.24 on the 25/9/24
6. The last entry on the 25/9/24 is at 14.35 and the next entry is not until 17.59 on the 26/9/24
7. The final entry on the 26/9/24 is at 20.54 and the first entry on the 27/9/24 is at 10.03.
These records therefore have gaps of up to 27 hours.
In addition the vast majority of records that do exist do not reveal whether Mr Coffey was actually repositioned as only one position is recorded. It is only on about 7 or 8 occasions that a repositioning has been recorded.
The medical records from the hospital do not show repositioning every 2-4 hours and I found that Mr Coffey was probably not repositioned as required. In the particular circumstances of Mr Coffey this did not contribute to his death lack of repositioning does give rise to a risk of future deaths of those suffering from chest infections or, indeed, those particularly at risk of pressure damage.
” 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 Operate the Harm Free Care Audit Programme to test timely assessments and implementation of pressure-injury interventions.
Verbatim wording from the response “A formal Harm Free Care Audit Programme is in place (commenced July 2025). The pressure injury prevention sections test out whether assessments have been done in a timely manner and whether the appropriate care interventions such as repositioning have been put in place. The audit in July 25 showed a 20% improvement in the documentation of the interventions from a previous audit (60% to 80%) compliance.” Source location Response from Frimley Health NHS Foundation 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 Disseminate EPR bulletins and targeted communications reinforcing timely, accurate repositioning documentation.
Verbatim wording from the response “The Trust has also launched a targeted staff communication campaign, including the distribution of an EPR Bulletin to all relevant clinical teams, these are regularly shared to highlight key educational messages to staff. I understand that the Bulletin reinforcing the importance of timely and accurate documentation of patient repositioning was shared with your office in early July. To further support staff, the Trust has expanded our Digital Ambassadors Network, providing peer-to-peer training and access to ‘training buddies’ who can assist with EPR-related queries and reinforce best practice.” Source location Response from Frimley Health NHS Foundation 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 Maintain system-driven EPR prompts that automatically trigger repositioning tasks at defined intervals and support ward- and patient-level auditing.
Verbatim wording from the response “• While Purpose T recommends repositioning, it does not prompt it directly. Accordingly, we have worked with our electronic patient record (“EPR”) supplier EPIC to introduce task prompts at defined intervals, visible on the care plan interface to support compliance (as below). This work forms part of a broader pressure ulcer improvement programme aligned with the National Wound Care Strategy.” Source location Response from Frimley Health NHS Foundation 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 education sessions and ward-based support on repositioning documentation, risk assessment and effective EPIC use.
Verbatim wording from the response “Education sessions have also been delivered, and in addition the Trust Clinical Education and Practice Development Teams have been visited wards to support staff in practice with documentation of repositioning, risk assessments and using EPIC effectively.” Source location Response from Frimley Health NHS Foundation 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 Expand the Digital Ambassadors Network to provide peer training and EPR support for clinical staff.
Verbatim wording from the response “The Trust has also launched a targeted staff communication campaign, including the distribution of an EPR Bulletin to all relevant clinical teams, these are regularly shared to highlight key educational messages to staff. I understand that the Bulletin reinforcing the importance of timely and accurate documentation of patient repositioning was shared with your office in early July. To further support staff, the Trust has expanded our Digital Ambassadors Network, providing peer-to-peer training and access to ‘training buddies’ who can assist with EPR-related queries and reinforce best practice.” Source location Response from Frimley Health NHS Foundation Trust
Open published response
3 Jun 2024 Isabella MCCREADIE · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Insufficient staffing in the dietetics department to address patients' dietetic needs View source Insufficient training of agency staff to record medical care on the ward computer system View source Staff lacking knowledge of techniques for repositioning patients with multiple injuries View source Failure to identify unreleased Fortisip orders on the hospital computer system View source Staff lacking training to support and handle patients in pain who refuse repositioning 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
Isabella MCCREADIE · 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
Isabella McCreadie, aged 90, suffered a fall at home causing fractures, was admitted to hospital and underwent surgery. She developed low haemoglobin, delirium and a hospital-acquired stage 4 pressure sore, and died of pneumonia at home on 6 June 2023. Concerns included insufficient dietetic staffing, pressure-sore care and training, an unprocessed dietary supplement order, and inadequate training for some agency staff using the hospital’s computer system.
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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing in the dietetics department to address patients' dietetic needs
Wider context from the report “1. In evidence I was advised during Mrs McCreadie's stay in hospital her dietetic needs were not addressed as there was insufficient staffing in the dietician department . I asked the hospital when giving evidence if these issues had been addressed and was advised that there were still ongoing . I am concerned that if appropriate staffing levels are not put in place, patient's needs will not be met .
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training of agency staff to record medical care on the ward computer system
Wider context from the report “4. At the time of the inquest, I was informed during Mrs McCreadie's stay a number of staff were agency staff. I note that the hospital now have more permanent staff in place on the ward than when Mrs McCreadie was on the ward. I remain concerned that agency staff who may still need to be called to assist on the ward may not have sufficient training on the computer system used for recording medical care provided before they are required to do so whilst working on the ward . At the inquest there was evidence that insufficient training had been given and therefore there were inconsistencies in recording of treatment given or needed . I understand permanent staff receive 9 hours of training, whereas agency staff may receive only up to 1 hour of training .
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Staff lacking knowledge of techniques for repositioning patients with multiple injuries
Wider context from the report “2. During evidence I was advised that a training need had been identified for staff regarding pressure sores following the passing of Mrs McCreadie. I have been advised in submissions by the hospital that they intend to address this training need by identifying e-learning staff can complete. Given in evidence it was identified that a) some staff do not know how to support and or handle patients who are in pain and refuse to be repositioned; and b) the staff are unaware of the techniques needed to be used to reposition patients who have multiple injuries , I do not consider that these can be adequately addressed by e-learning.
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify unreleased Fortisip orders on the hospital computer system
Wider context from the report “3. During the doctor's evidence, at inquest, an issue was highlighted regarding ordering of fortisips on the hospital computer system, a dietary supplement. An order had been made to be started on 10th May to 3rd June twice daily. This was not processed. I was advised in evidence by the hospital that the doctor could be shown how to release it. However, there is no evidence as to how this error could be identified if it should occur and a clinician was not aware that the order for fortisips was not released 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Staff lacking training to support and handle patients in pain who refuse repositioning
Wider context from the report “2. During evidence I was advised that a training need had been identified for staff regarding pressure sores following the passing of Mrs McCreadie. I have been advised in submissions by the hospital that they intend to address this training need by identifying e-learning staff can complete. Given in evidence it was identified that a) some staff do not know how to support and or handle patients who are in pain and refuse to be repositioned ; and b) the staff are unaware of the techniques needed to be used to reposition patients who have multiple injuries, I do not consider that these can be adequately addressed by e-learning.
” 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 therapy directorate demand and capacity and compile a dietetics staffing proposal.
Verbatim wording from the response “A review is currently being undertaken to look at demand and capacity for the whole of the therapy’s directorate including the dietetics team and a staffing proposal paper is being compiled. The Trust seeks to reassure you that resources in the dietetics team are being used as effectively as possible to ensure patient’s needs are appropriately met and bank work is being offered where appropriate.” Source location Response from Frimley NHS
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 in-person manual-handling induction and refresher training covering repositioning complex patients and supporting patients who resist because of pain.
Verbatim wording from the response “Currently, nursing staff and healthcare support workers receive manual handling training in person on induction which provides training on how to reposition patients. This training is 4 hours on induction for any nurse or healthcare support worker with prior healthcare experience and 6 hours for anyone without prior clinical experience. Refresher training is provided online every 3 years.” Source location Response from Frimley NHS
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 Participate in the national dietetics staffing benchmarking programme and submit Trust data.
Verbatim wording from the response “The Trust has engaged with a national benchmarking programme which is being managed by the British Dietetic Association who feel that the current national safe staffing guidance for dietetics needs to be updated. This is based on the fact that 55% of respondents to the British Dietetic Association questionnaire felt there was unsafe staffing within their dietetics team. We feel that this illustrates that resourcing for dietetics is a national issue.” Source location Response from Frimley NHS
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 Require agency staff to complete online and classroom Epic training, including an end-of-training assessment, before working a Trust shift.
Verbatim wording from the response “Since October 2023 agency staff have been required to complete one hour of online training and 4 hours classroom based Epic training in person before they can work a shift at the Trust.” Source location Response from Frimley NHS
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 access to Dolphin specialist mattresses with supplier training, clinical monitoring and tissue-viability referral support.
Verbatim wording from the response “The Trust also now has access to a new specialist mattress called a “Dolphin” which can be used in conjunction with a tilting bed frame, designed to manage patients who find repositioning extremely painful. The ward staff receive training from the company who supply the equipment and the use of the mattress is monitored by the company with weekly visits from the supplier’s clinical adviser. There is also access to an electronic help line which can be used for any issues which arise. Staff request the dolphin mattress for patients via the Trust’s tissue viability nurse. This ensures that these patients, who are at risk of pressure injuries due to the fact they find repositioning painful, are also receiving input from the tissue viability team.” Source location Response from Frimley NHS
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 Carry out a ward-level quality improvement project to prevent malnutrition and improve first-line supplement provision.
Verbatim wording from the response “In April 2024 the Head of Dietetics, Speech and Language Therapy and Podiatry at Frimley Health NHS Foundation Trust, who chairs the Fundamental and Better Care council for the Trust commenced a quality improvement project focusing on interventions at a ward level to prevent malnutrition in our patients. This is due to be completed by March 2025. One of the key aims of this improvement project is to ensure patients at risk of malnutrition are being given first-line oral nutritional supplements. The possible solutions to be trialled are:” Source location Response from Frimley NHS
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 Investigate clarifying Epic’s best-practice advisory to remind staff about first-line supplements for MUST scores of one or above.
Verbatim wording from the response “The Trust are investigating whether it is possible to clarify the wording on the best practice advisory box in Epic to remind nursing staff of this guideline whenever a Malnutrition Universal Screening Tool (MUST) score of 1 or above is inserted into Epic.” Source location Response from Frimley NHS
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 Move dietetics resource from Wexham Park Hospital to Frimley Park Hospital to meet higher acute-team demand.
Verbatim wording from the response “Earlier this year, some resource was moved from the Wexham Park Hospital dietetics team to Frimley Park Hospital to meet the higher demand in the acute team at Frimley Park Hospital.” Source location Response from Frimley NHS
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 Existing in-person induction and refresher training addresses repositioning complex or resisting patients, so eLearning alone is not considered adequate or necessary.
Verbatim wording from the response “I do not consider that these can be adequately addressed by eLearning.” Source location Response from Frimley NHS
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 Fortisip Compact Protein does not require prescription or Epic release before administration, and the relevant order was auto-released and administered promptly.
Verbatim wording from the response “Fortisip Compact Protein is a fortified nutritional supplement and as an Advisory Committee on Borderline Substances (ACBS) approved product it does not need to be prescribed and as such does not need to be released on the Trust’s electronic patient record (Epic) before it can be given. Fortisip Compact Protein can be given to a patient by a dietitian, doctor or nurse who has undergone relevant online training compiled by the dietetics team. First-line oral nutritional supplements should be given to any patient who is scored at 1 or above on the Malnutrition Universal Screening Tool (MUST) and for whom the supplement is clinically safe.” Source location Response from Frimley NHS
Open published response
26 Apr 2024 Ellen Mercer · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 2 Failure of policy to clearly define a 24-hour VTE risk assessment period that accounts for emergency department waits View source Failure of current policies to require VTE risk assessment for emergency department patients during prolonged waits 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.
×
AI-generated summary
Ellen Mercer · 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
Ellen Mercer attended Wexham Park Hospital by ambulance in the early hours of 9 February 2023 after deterioration associated with her mental health, nitrous oxide use, leg injuries and reduced mobility. She died in the emergency department approximately 24 hours after arriving; a post-mortem examination identified bilateral pulmonary artery thromboembolus and deep vein thrombosis. The substantive concerns relate to the absence of a formal VTE risk assessment and uncertainty in hospital policies about when the 24-hour period for such an assessment begins, particularly for patients waiting in 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of policy to clearly define a 24-hour VTE risk assessment period that accounts for emergency department waits
Wider context from the report “1. Patients are unfortunately waiting increasingly longer times in emergency departments – not just in waiting areas, but also after being seen by clinical staff and waiting for admission to a ward or discharge from the hospital. During this time, current policies do not require VTE risk assessment.
2. The policy for this trust suggests that the 24 hour period (during which VTE risk assessment must take place) starts only when a patient is “admitted” to hospital, i.e. when a decision is taken to admit them to a ward – which could be many hours after they have originally attended the emergency department.
3. The policy as currently drafted implies that VTE risk assessment is essentially not relevant for emergency department patients.
4. If current policies require VTE risk assessment to take place within 24 hours, the point at which that 24 hour period starts is not sufficiently clear and does not take long waits in emergency departments into account. I am concerned that policies may need to reflect the current reality on the ground.
5. I suspect that this issue may be a national one.
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of current policies to require VTE risk assessment for emergency department patients during prolonged waits
Wider context from the report “1. Patients are unfortunately waiting increasingly longer times in emergency departments – not just in waiting areas, but also after being seen by clinical staff and waiting for admission to a ward or discharge from the hospital. During this time, current policies do not require VTE risk assessment.
2. The policy for this trust suggests that the 24 hour period (during which VTE risk assessment must take place) starts only when a patient is “admitted” to hospital, i.e. when a decision is taken to admit them to a ward – which could be many hours after they have originally attended the emergency department.
3. The policy as currently drafted implies that VTE risk assessment is essentially not relevant for emergency department patients.
4. If current policies require VTE risk assessment to take place within 24 hours, the point at which that 24 hour period starts is not sufficiently clear and does not take long waits in emergency departments into account. I am concerned that policies may need to reflect the current reality on the ground.
5. I suspect that this issue may be a national one.
” Open source report
Concerns raised 2 Failure to undertake a mental health assessment following self-harm or suicidal ideation View source Failure to record suicidal ideation identified during emergency department care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ryan John EVANS · 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
Ryan John EVANS died after being found hanging in the communal area of his accommodation on 3 April 2018. The concerns included that, despite evidence of self-harm and suicidal ideation, no mental health assessment was carried out at hospital, and that mental health information and referrals were not effectively documented or communicated during his time in police custody.
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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a mental health assessment following self-harm or suicidal ideation
Wider context from the report “An emergency department consultant at Frimley Park gave evidence which suggested that no mental health assessment was or would have been necessary where Ryan’s presenting complaint was recorded as chest pains rather than of self-harm and/or suicidal ideation . Although self-harm had been noted in the records, no explanation could be provided for why Ryan’s suicidal ideation had not been recorded.
The consultant was further questioned in relation to the 2006 NICE Guidelines “Self-Harm: the short term physical and psychological management and secondary prevention of self-harm in primary and secondary care” which are national guidelines that ought to feed into practice at the hospital.
These guidelines provide that “Following triage patients who have self-harmed should receive the requisite treatment for their physical condition, undergo risk and full psychosocial needs assessment and mental state examination, and referral for further treatment and care as necessary” and “All people who have self harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.”
Evidence received during the course of the Inquest was not able to reconcile the contradiction between the NICE guidelines on self-harm and Mr. EVANS having had no mental health assessment despite obvious signs of self-harm and further evidence of disclosure of suicidal ideation .
The jury in their Narrative Conclusion found that ‘Despite evidence of self-harm, no mental health assessment was carried out at this point. ’
I remain concerned as to how such a situation would be avoided if a patient presented again in similar manner to Mr. EVANS. The additional evidence on PFD matters provided by Frimley Health NHS Foundation Trust does not refer to or address the NICE guidelines on self-harm or explain what would now be done differently were a patient such as Mr. EVANS were to be seen again.
The Frimley Health NHS Foundation Trust additional evidence refers to matters being in the process of introduction and new referral criteria with Surrey and Borders Partnership NHS Foundation Trust, but this does not explain how this would prevent the future risk of a patient such as Mr. EVANS leaving the hospital without a mental health assessment .
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record suicidal ideation identified during emergency department care
Wider context from the report “An emergency department consultant at Frimley Park gave evidence which suggested that no mental health assessment was or would have been necessary where Ryan’s presenting complaint was recorded as chest pains rather than of self-harm and/or suicidal ideation. Although self-harm had been noted in the records, no explanation could be provided for why Ryan’s suicidal ideation had not been recorded.
The consultant was further questioned in relation to the 2006 NICE Guidelines “Self-Harm: the short term physical and psychological management and secondary prevention of self-harm in primary and secondary care” which are national guidelines that ought to feed into practice at the hospital.
These guidelines provide that “Following triage patients who have self-harmed should receive the requisite treatment for their physical condition, undergo risk and full psychosocial needs assessment and mental state examination, and referral for further treatment and care as necessary” and “All people who have self harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.”
Evidence received during the course of the Inquest was not able to reconcile the contradiction between the NICE guidelines on self-harm and Mr. EVANS having had no mental health assessment despite obvious signs of self-harm and further evidence of disclosure of suicidal ideation.
The jury in their Narrative Conclusion found that ‘Despite evidence of self-harm, no mental health assessment was carried out at this point.’
I remain concerned as to how such a situation would be avoided if a patient presented again in similar manner to Mr. EVANS. The additional evidence on PFD matters provided by Frimley Health NHS Foundation Trust does not refer to or address the NICE guidelines on self-harm or explain what would now be done differently were a patient such as Mr. EVANS were to be seen again.
The Frimley Health NHS Foundation Trust additional evidence refers to matters being in the process of introduction and new referral criteria with Surrey and Borders Partnership NHS Foundation Trust, but this does not explain how this would prevent the future risk of a patient such as Mr. EVANS leaving the hospital without a mental health assessment.
” 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 Conduct nurse-led mental health assessments for patients disclosing mental health issues or self-harm, assessing immediate risk, abscondence risk and enhanced-care needs.
Verbatim wording from the response “Whenever a patient reveals a history of mental health issues or self-harm, either by overt presentation or by disclosing it when asked at triage, a further mental health assessment is undertaken by a nurse within the Emergency Department. Please find attached a copy of the Mental Health Triage Tool now used in the Emergency Department.” Source location Response from Frimley Health
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 Maintain joint governance arrangements with Psychiatric Liaison services for integrated physical and mental healthcare, including shared records, referral pathways, assessment, safeguarding and observation procedures.
Verbatim wording from the response “In accordance with paragraph 1.1.17 of the NICE guideline [NG225] Frimley Park Hospital and Surrey and Borders Partnership ensure that appropriate joint governance arrangements are in place so that physical and mental healthcare can be delivered together in the emergency department at Frimley Park Hospital. As set out in the NICE guideline this includes the following:” Source location Response from Frimley Health
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 Store Emergency Department triage and mental health assessment forms electronically in the patient record, with Psychiatric Liaison access.
Verbatim wording from the response “Both the initial Emergency Department triage and the mental health assessment form are now held electronically on the Trust’s electronic patient record, to which the Psychiatric Liaison services team have access. This means that, if necessary, a patient’s entire medical record can be referred to by Psychiatric Liaison services.” Source location Response from Frimley Health
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 Emergency Department digital triage to ask all patients about mental health or self-harm within 15 minutes of arrival.
Verbatim wording from the response “In response to this NICE guideline and additional guidance from the Royal College of Emergency Medicine (RCEM), ‘Mental Health in Emergency Department’s – A Toolkit for Improving care’, April 2021, the Trust has now updated its digital triage assessment of all patients attending the Emergency Department to include a mandatory question about a patient’s history of mental health and/or self-harm. This question is asked of all patients attending the Emergency Department within 15 minutes of their arrival regardless of the reason for their presentation.” Source location Response from Frimley Health
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 Emergency Department clinicians with mental health triage training during induction and supervised shadowing before independent assessment.
Verbatim wording from the response “Clinicians in the Emergency Department are now provided with training on mental health triage assessment during their induction and go on to shadow other staff completing the mental health triage assessments before carrying them out independently.” Source location Response from Frimley Health
Open published response
7 Mar 2022 ARTHUR FREDERICK HALL · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 8 Insufficient discharge advice for potentially time-critical complaints View source Failure to account for the limited sensitivity of upright chest X-rays when excluding perforation View source Failure to recognise signs of sepsis View source Failure to perform further abdominal examination before discharge View source Failure to undertake second-line investigation of suspected perforation View source Failure to complete investigation of suspected bowel perforation View source Failure to seek surgical opinion for suspected post-surgical symptoms View source Failure to recognise post-surgical pain or sickness as indicators of serious complications View source See 5 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
ARTHUR FREDERICK HALL · 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
Arthur Frederick Hall developed a perforation following an elective colonoscopy with polypectomy on 31 January 2018. He was discharged from A&E after presenting with abdominal symptoms, later returned with sepsis and underwent emergency surgery, but died on 2 March 2018 from overwhelming sepsis and multiple organ failure. The principal concerns included inadequate investigation and assessment of possible bowel perforation, unclear discharge advice, failure to obtain surgical input, and missed signs of sepsis.
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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient discharge advice for potentially time-critical complaints
Wider context from the report “5. Given the potential time-critical nature of Arthur’s possible complaint, more detailed discharge advice should have been given .
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for the limited sensitivity of upright chest X-rays when excluding perforation
Wider context from the report “2. The recognised first line of enquiry was an upright chest X-ray. What is known about upright chest Xray’s is that they are known to miss a number of perforations. This was used to exclude the possibility of perforation when it is a known limited diagnostic tool that can miss from 20% of perforations to 50% of perforations (see literature).
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise signs of sepsis
Wider context from the report “8. Signs of sepsis were 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform further abdominal examination before discharge
Wider context from the report “7. No further examination of abdomen was undertaken prior to discharge .
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake second-line investigation of suspected perforation
Wider context from the report “3. Second line of enquiry (endoscopy or CTPA) was not undertaken .
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete investigation of suspected bowel perforation
Wider context from the report “1. On the 1st February 2018 the differential diagnosis of bowel perforation was abandoned without full investigation .
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek surgical opinion for suspected post-surgical symptoms
Wider context from the report “6. No surgical opinion was sought when a surgical patient attended A&E with symptoms which were suspected to be related to 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise post-surgical pain or sickness as indicators of serious complications
Wider context from the report “4. Assumptions were made that pain was a result of surgery and therefore not considered an important indicator of a problem . The surgery is considered by practitioners to be painless, and that pain or sickness are signs of potentially serious complications .
” Open source report
3 Nov 2021 Angela Margaret O’Donnell · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 2 Shortage of nursing staff View source Reliance on agency nursing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Angela Margaret O’Donnell · 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
Angela Margaret O’Donnell, who had advanced lung cancer, was admitted to hospital with confusion and pain and died in hospital on 14 January 2020. The report identifies incomplete NEWS charting and missed opportunities to escalate her deteriorating condition, while stating that this was not found to have caused her death. The principal concern was reliance on agency nurses, who may not receive the trust’s refresher training and related communications, in the context of wider nursing staff shortages.
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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Shortage of nursing staff
Wider context from the report “(2) What plans are there nationally to reduce the shortage of nursing staff going forward ? This question is for the Secretary of State.
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on agency nursing staff
Wider context from the report “(1) Is the trust able to carry out any steps to reduce their reliance on agency nursing staff – for instance, by using nurses from a smaller pool of their own bank staff who receive the same training as permanent staff, or any other similar measures? This question is for the hospital trust.
” 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 Encourage substantive and former permanent staff to undertake shifts through the Trust’s staff bank.
Verbatim wording from the response “2. Encouraging our substantive staff to undertake bank shifts and increasing the number of ‘bank nurses’ we employ” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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 Continue targeted and general recruitment campaigns to increase the substantive nursing workforce.
Verbatim wording from the response “I will explain how we are aiming to reduce our reliance on agency nursing staff by:” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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 Continue international nurse recruitment and provide recruited nurses with examination preparation, registration support and preceptorship.
Verbatim wording from the response “International recruitment forms a large part of our nursing recruitment activity, with 172 international nurses recruited in 2019/20 and around 200 so far in 2020/21. We have an ambition to increase our international nurse recruitment to around 400 nurses throughout 2022, with additional funding from NHSE/I to support this.” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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 trainee nursing associate and degree apprenticeship routes to develop nursing staff.
Verbatim wording from the response “We offer various training routes into registered nursing through Trainee Nursing Associate (TNA) and Degree Apprenticeship routes. Over the last few years we have successfully supported 50 Care Assistants through their Nursing Associate (NA) training and currently have a further 57 staff on their TNA programme. These programmes have continued to grow each year and it is hoped that this will help stabilise our substantive nursing workforce over the next three years and reduce our reliance on temporary staffing.” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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 Continue recruiting healthcare support workers through recruitment drives, apprenticeships and Care Certificate training.
Verbatim wording from the response “Our registered nursing workforce is also supported by healthcare support workers. The Trust regularly undertakes recruitment drives to meet the national target of zero healthcare support worker vacancies. This is again supported by offering additional training through apprenticeship routes and the Care Certificate, with additional funding currently being provided by NHSE/I to support this initiative. 209 care assistants have started in the Trust over the last 12 months with a further 93 having been recruited who are currently completing their pre-employment checks.” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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 Recruit a Trust People Promise Manager to support workforce retention and wellbeing.
Verbatim wording from the response “The Trust recognises the importance of retaining staff as well as recruitment, this is vital to achieving a safe and sustainable workforce. We understand that retention of nursing staff is a recognised challenge nationally and we are working hard to improve staff wellbeing as a cornerstone of this issue.” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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 student placement capacity to expand the future nursing workforce.
Verbatim wording from the response “We also look to increase our student placement capacity year on year to increase the number of nursing staff in training. It is intended aim that these nurses will then continue in substantive roles within the Trust upon qualification.” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
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 Trust will not address or comment on the national nursing shortage because that issue falls outside this response’s remit.
Verbatim wording from the response “I recognise the point you have made about the reliance on agency staffing being a national issue for the NHS and that you have also directed your concerns to the Secretary of State for Health. It would not be appropriate for me to seek to address or comment on the national issue in this response, but I hope to set out what Frimley Health NHS Foundation Trust is doing to address your first concern listed above.” Source location 2021-0370-Response-from-Frimley-Park-Hospital_Published
Open published response
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.
×
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.
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 Frimley Health NHS Foundation 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 Frimley Health NHS Foundation 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 Frimley Health NHS Foundation 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 Frimley Health NHS Foundation 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 Frimley Health NHS Foundation 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 Frimley Health NHS Foundation 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
11 Jul 2014 Maria De Oliveria Alva LOPES · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 19 Lack of daily creatine kinase monitoring during propofol infusions View source Lack of national understanding and acceptance of safe propofol amounts View source Lack of consultant ward rounds in weekend urology on-call arrangements View source Delays in urology review of emergency admissions View source Failure to act on or escalate elevated Early Warning Scores View source Undue reliance on outdated admission blood tests for clinical assessment View source Failure to create and adhere to guidelines or protocols for propofol use View source Lack of active management to expedite physician review and ITU admission View source Failure to recognise and treat sepsis in accordance with national guidelines View source Lack of continual assessment for complications of propofol-related infusion syndrome View source Lack of clarity about propofol infusion duration, volume and dose View source Inadequate assessment of renal stone size and hydronephrosis View source Lack of a protocol for propofol use in ITU View source Inadequate supervision of out-of-hours urology trainees View source Lack of medical supervision and control of propofol use in ITU View source Lack of knowledge or implementation of published on-call national guidelines View source Lack of understanding that propofol-related infusion syndrome is a complication of prolonged propofol sedation View source Lack of understanding of atypical adult presentation of propofol-related infusion syndrome View source Failure of critical care outreach to recognise and escalate concerns of sepsis View source See 16 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
Maria De Oliveria Alva LOPES · 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
Maria De Oliveria Alva LOPES died on 9 September 2012 after developing severe sepsis from an obstructing ureteric stone, followed by septic shock, multiorgan failure and rhabdomyolysis associated with propofol-related infusion syndrome. The principal concerns included delayed recognition and escalation of sepsis, delays in intensive care admission and treatment, inadequate supervision and control of propofol use, and insufficient monitoring for propofol-related complications.
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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of daily creatine kinase monitoring during propofol infusions
Wider context from the report “12. Consideration for the use of daily Creatine Kinase levels when propofol infusions are given
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national understanding and acceptance of safe propofol amounts
Wider context from the report “15. Lack of national understanding and acceptance of the amount of propofol that can be given and the importance of creating and adhering to guidelines or protocols for its use and to implement continual assessment to look for the complications of PRIS (serial CK levels)
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consultant ward rounds in weekend urology on-call arrangements
Wider context from the report “1. The consultant urologist’s on call arrangements covering three hospitals at the weekend has no provision for consultant ward rounds , in contravention of suggested national guidelines
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in urology review of emergency admissions
Wider context from the report “4. The review of emergency admissions by urology (not on day of admission, once daily )
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on or escalate elevated Early Warning Scores
Wider context from the report “9. Failure to act on or escalate elevated Early Warning Scores as per hospital protocol
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Undue reliance on outdated admission blood tests for clinical assessment
Wider context from the report “6. The assessment and size of the renal stone and hydronephrosis, and undue reliance on blood tests taken on admission (18 hours previously) to assess Mrs Lopes’s condition
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to create and adhere to guidelines or protocols for propofol use
Wider context from the report “15. Lack of national understanding and acceptance of the amount of propofol that can be given and the importance of creating and adhering to guidelines or protocols for its use and to implement continual assessment to look for the complications of PRIS (serial CK levels)
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of active management to expedite physician review and ITU admission
Wider context from the report “7. The lack of active management to expedite physician’s review and to facilitate admission to ITU
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and treat sepsis in accordance with national guidelines
Wider context from the report “5. The recognition and treatment of sepsis as per national guidelines
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of continual assessment for complications of propofol-related infusion syndrome
Wider context from the report “15. Lack of national understanding and acceptance of the amount of propofol that can be given and the importance of creating and adhering to guidelines or protocols for its use and to implement continual assessment to look for the complications of PRIS (serial CK levels)
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about propofol infusion duration, volume and dose
Wider context from the report “10. Lack of clarity to the length, volume and dose of propofol infusion to be given in ITU
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate assessment of renal stone size and hydronephrosis
Wider context from the report “6. The assessment and size of the renal stone and hydronephrosis , and undue reliance on blood tests taken on admission (18 hours previously) to assess Mrs Lopes’s condition
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for propofol use in ITU
Wider context from the report “11. Lack of medical supervision and control of the use of propofol in ITU (no protocol in place )
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate supervision of out-of-hours urology trainees
Wider context from the report “3. The overall supervision of out of hours urology trainees within the current 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of medical supervision and control of propofol use in ITU
Wider context from the report “11. Lack of medical supervision and control of the use of propofol in ITU (no protocol in place)
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge or implementation of published on-call national guidelines
Wider context from the report “2. A general lack of knowledge or implementation of published ‘on call’ national guidelines
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding that propofol-related infusion syndrome is a complication of prolonged propofol sedation
Wider context from the report “13. Lack of understanding and acceptance Propofol related infusion syndrome (PRIS) is an accepted albeit rare, complication of the use of prolonged propofol for sedation in Intensive Care Units
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of atypical adult presentation of propofol-related infusion syndrome
Wider context from the report “14. Lack of understanding that PRIS may have an atypical presentation in adults and should always be a consideration when propofol is used for a protracted period of time
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of critical care outreach to recognise and escalate concerns of sepsis
Wider context from the report “8. Failure to recognise and therefore escalate concerns of sepsis by critical care outreach team
” 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 the three-hospital urology on-call services and develop an action plan toward seven-day compliance.
Verbatim wording from the response “This has set out standards which would mean that all emergency in patients would be assessed by a suitable consultant within six hours, (during periods of consultant presence on an acute ward) and, at other times, must have a thorough clinical assessment by a suitable consultant within 14 hours of arrival in hospital. Implementation of this guidance is over the next three years, with a submission of action plans in 2014/15, implementation of the greatest impact changes in 2015/16 and compliance by 2016/17. These standards represent a paradigm shift from the usual on-call arrangements concerning urology in the majority of hospitals in this country. The three trusts will need to undertake a review of the on-call services to develop an action plan towards becoming compliant with 7-day working.” Source location 2014-0325-Response-by-Frimley-Park-Hospital
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 weekend urology review and supervision through consultant ward rounds, registrar emergency assessments, case discussion and consultant availability.
Verbatim wording from the response “When the consultant urologists' on-call rota was established covering North Hampshire Hospital, Royal Surrey County Hospital and Frimley Park Hospital, the agreement was that trusts would make their own arrangements for review of in-patients/emergencies at the weekend. I believe that we have robust arrangements at Frimley Park Hospital, with the consultant on-call on Friday night available to see admissions and a Saturday morning ward round by Specialist Registrar or equivalent who reviews all emergency admissions and in-patients. These cases are then discussed with the consultant who had been on-call on the Friday night. A Frimley Park Hospital consultant is available to come to see these patients. The on-call consultant on the rota is then available for advice and we” Source location 2014-0325-Response-by-Frimley-Park-Hospital
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 No specific national urology on-call guidelines existed; the cited recommendations were recent and not yet fully implemented.
Verbatim wording from the response “There are no current suggested national guidelines concerning the provision of consultant ward rounds but we believe this is a reference to the guidelines produced by Sir Bruce Keogh in a paper presented to NHS England in December 2013, outlining seven days a week service.” Source location 2014-0325-Response-by-Frimley-Park-Hospital
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 Existing weekend arrangements provide registrar and consultant review of urology emergency admissions and inpatients.
Verbatim wording from the response “When the consultant urologists' on-call rota was established covering North Hampshire Hospital, Royal Surrey County Hospital and Frimley Park Hospital, the agreement was that trusts would make their own arrangements for review of in-patients/emergencies at the weekend. I believe that we have robust arrangements at Frimley Park Hospital, with the consultant on-call on Friday night available to see admissions and a Saturday morning ward round by Specialist Registrar or equivalent who reviews all emergency admissions and in-patients. These cases are then discussed with the consultant who had been on-call on the Friday night. A Frimley Park Hospital consultant is available to come to see these patients. The on-call consultant on the rota is then available for advice and we” Source location 2014-0325-Response-by-Frimley-Park-Hospital
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 Consultant-delivered emergency services with regular inpatient ward rounds require additional consultant appointments before compliance can be achieved.
Verbatim wording from the response “3. The overall supervision of out-of-hours urology trainees within the system
The overall supervision of out-of-hours' urology trainees within the current system is specific to the arrangements within each Trust. Trainees have access to consultant advice and review, if necessary, 24/7 during the on-call weekend. Provision of consultant-delivered emergency service with regular in-patient ward rounds will require additional consultant appointments to allow trusts to become compliant with Keogh. There is wide variety of provision of urology cover across the country, with approximately 50% of urology departments dependent on general surgical middle grade support. We are fortunate to have urology middle grade support for our emergencies. It is recognised by BAUS that this is an issue that will need to be addressed in the next couple of years.” Source location 2014-0325-Response-by-Frimley-Park-Hospital
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 Existing arrangements provide safe, supervised out-of-hours trainee practice through registrar discussions and consultant advice or review when required.
Verbatim wording from the response “2. A general lack of knowledge or implementation of published ‘on-call’ national guidelines
As mentioned above, there are no specific on-call guidelines produced nationally for urology and the Keogh recommendations were published within the last year. These have therefore come into force subsequent to Mrs Lopez's tragic death and it is intended that consultants from all three hospitals meet to discuss future arrangements for on-call. The current on-call arrangements at Frimley Park Hospital have operated safely for over ten years and, by discussing cases with the registrar on Saturday and reviewing collaborative decisions made by the registrars the next day, we are able to provide supervision of the registrars. In addition, the on-call consultant for all three hospitals is able to review patients, if requested.” Source location 2014-0325-Response-by-Frimley-Park-Hospital
Open published response
24 Mar 2014 Phyllis Barnes · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Superficial and perfunctory nurse-led telephone consultations for enhanced recovery after laparoscopic surgery View source Failure of visiting general practitioners to appreciate the seriousness of patients’ conditions View source Lack of formal communication opportunities for patients’ relatives to report patients’ conditions to primary care clinicians View source Unreliable promised telephone follow-up View source See 1 more concern
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
Phyllis Barnes · 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
Phyllis Barnes underwent elective laparoscopic anterior resection and was discharged home, but developed persistent vomiting and became increasingly unwell. She was later readmitted with an anastomotic leak and died from complications. Concerns included delayed recognition of the seriousness of her symptoms, a superficial nurse-led telephone consultation with uncertain follow-up, and a lack of formal communication with her daughter.
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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Superficial and perfunctory nurse-led telephone consultations for enhanced recovery after laparoscopic surgery
Wider context from the report “2. Inappropriate nurse-led telephone consultation for the enhanced recovery programme for laparoscopic surgery appears to have been superficial and perfunctory with doubts over a further telephone follow-up as promised
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of visiting general practitioners to appreciate the seriousness of patients’ conditions
Wider context from the report “1. Failure of visiting General Practitioner to appreciate the seriousness of Mrs Barnes condition in view of her recent operation and persistent 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal communication opportunities for patients’ relatives to report patients’ conditions to primary care clinicians
Wider context from the report “3. There was no formal communication or opportunity for Mrs Barnes’s daughter to relate her mother’s condition to the GP or the Nurse Practitioner
” 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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unreliable promised telephone follow-up
Wider context from the report “2. Inappropriate nurse-led telephone consultation for the enhanced recovery programme for laparoscopic surgery appears to have been superficial and perfunctory with doubts over a further telephone follow-up as promised
” Open source report
24 Oct 2013 Peter Clive HIGSON · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Potential contraindication of platelet transfusion following stem cell transplant 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.
×
AI-generated summary
Peter Clive HIGSON · 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
Peter Clive Higson had treated Hodgkin’s lymphoma and underwent an autologous stem cell transplant before being admitted to hospital with severe illness. After platelet transfusions, his breathing and overall condition deteriorated; the principal concern was whether the transfusions, possibly interacting with the stem cell transplant, contributed to the chain of events leading to his death.
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 Frimley Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Potential contraindication of platelet transfusion following stem cell transplant
Wider context from the report “The platelet transfusion (12 & 13th March 2013) following the stem cell transplant (28th January 2013, seemed to have a major detrimental effect on the deceased and features, if only chronologically, in the ultimate chain of causation leading to his death.
A question arises as to whether there was any aspect of e.g., the stem cell transplant interacting with the platelet transfusion suggesting that on occasions such transfusion might be contra-indicated .
” 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