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.
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
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 Park Hospital; 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 Park Hospital; 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 Park Hospital; 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 Park Hospital; 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 Park Hospital; 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
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.
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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 Park Hospital; 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 Park Hospital; 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 Park Hospital; 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 Park Hospital; 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 Park Hospital; 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 Park Hospital; 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 Park Hospital; 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 Park Hospital; 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.
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
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 Park Hospital; 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 Park Hospital; 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
Concerns raised 8 Incoherent and inconsistent sedation practice for catheter laboratory procedures View source Inappropriate use of sedation for cardiac electrophysiological procedures View source Lack of a sedation policy for cardiac electrophysiological procedures View source Lack of an action plan for obtaining assistance during airway loss or difficulty placing a pacemaker wire View source Lack of regular training in the safe and appropriate use of anxiolytics and analgesics View source Lack of an action plan for patients who do not tolerate the procedure View source Lack of understanding of required observations during the procedure View source Lack of knowledge of the policy for safe sedation outside the operating theatre environment 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
Peter John Keep · 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 John Keep, an 82-year-old man, was admitted after a fall and underwent pacemaker insertion for Mobitz type 2 heart block. During the difficult procedure he received several sedative and analgesic doses, lost his airway, and suffered cardiac tamponade from perforation of the right ventricle; he later had a cardiac arrest and died in intensive care. The principal concerns included inappropriate and inconsistent sedation, inadequate sedation policies and training, and a lack of action plans for procedure intolerance, airway loss, or difficulty placing the pacemaker wire.
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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Incoherent and inconsistent sedation practice for catheter laboratory procedures
Wider context from the report “3. An incoherent approach to sedation for procedures in the catheter Lab. with different clinicians using different drugs inconsistently e.g. use of an anxiolytic for discomfort.
” 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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Inappropriate use of sedation for cardiac electrophysiological procedures
Wider context from the report “1. Inappropriate use of sedation and a lack of a sedation policy for cardiac electrophysiological procedures.
” 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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a sedation policy for cardiac electrophysiological procedures
Wider context from the report “1. Inappropriate use of sedation and a lack of a sedation policy for cardiac electrophysiological procedures .
” 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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of an action plan for obtaining assistance during airway loss or difficulty placing a pacemaker wire
Wider context from the report “6. Lack of an action plan as to who to call for assistance in circumstances when a patient's airway is lost or there is difficulty in placing a pacemaker wire .
” 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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of regular training in the safe and appropriate use of anxiolytics and analgesics
Wider context from the report “4. No regular training for safe and appropriate use of anxiolytics and analgesics e.g. understanding their action and possible adverse effects or consideration of appropriate age related dosing .
” 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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of an action plan for patients who do not tolerate the procedure
Wider context from the report “5. Lack of an action plan for patients who do not tolerate the procedure .
” 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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of required observations during the procedure
Wider context from the report “7. Lack of understanding as to what observations are taken and are required during the procedure e.g. belief that the pulse oximeter measures respiratory rate
” 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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of the policy for safe sedation outside the operating theatre environment
Wider context from the report “2. An absence or a lack of knowledge of a Trust policy for safe sedation outside the operating theatre environment , which could therefore not be considered or implemented .
” Open source report
Concerns raised 2 Failure to seek appropriate senior medical advice before administering medication to a patient with a known allergy View source Failure to obtain informed consent for administering medication to which a patient has a known allergy 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
Marjory Rosina ELLERY · 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
Marjory Rosina Ellery was taken to Frimley Park Hospital with chest pains and was administered medication to which she was known to be allergic. She developed anaphylactic shock and died on 16 January 2014; concerns related to administering medication despite a known allergy and obtaining informed consent in those circumstances.
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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to seek appropriate senior medical advice before administering medication to a patient with a known allergy
Wider context from the report “1. Action is required to ensure that medication is not administered to a patient to which they are known to have an allergy without advice being sought from a doctor of appropriate designated seniority or experience .
” 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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain informed consent for administering medication to which a patient has a known allergy
Wider context from the report “2. Action is required to ensure that consent obtained from a patient as to the administration of medication to which there is a known allergy is informed consent .
” Open source report
20 Mar 2014 Jackson J Chadd · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Lack of effective supervision of non-career grade paediatricians without previous experience View source Lack of independent consultant assessment of paediatric admissions outside normal working hours View source Failure to acknowledge or act on parent concerns View source Lack of consultant supervision of out-of-hours on-call paediatric trainees View source Lack of effective application of national guidelines for assessment and investigation of fever in children less than one year of age View source See 2 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
Jackson J Chadd · 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
Jackson became unwell at home with fever, poor feeding, diarrhoea, a rash and abnormal observations, and was discharged from A&E with a diagnosis of gastroenteritis. He returned in septic shock and died despite resuscitation; the medical cause of death was fulminant meningococcal infection. Concerns included inadequate supervision and assessment, failure to apply fever guidelines, and failure to act on a parent’s concerns.
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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of effective supervision of non-career grade paediatricians without previous experience
Wider context from the report “1. Lack of effective supervision of a non-career grade paediatrician with no previous experience
” 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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of independent consultant assessment of paediatric admissions outside normal working hours
Wider context from the report “3. Lack of independent consultant assessment of paediatric admissions into Frimley Park Hospital outside normal working hours
” 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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to acknowledge or act on parent concerns
Wider context from the report “5. Failure to acknowledge or act on the concerns of a parent
” 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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of consultant supervision of out-of-hours on-call paediatric trainees
Wider context from the report “2. Lack of consultant supervision of ‘out of hours’ on-call paediatric trainees
” 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 Park Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of effective application of national guidelines for assessment and investigation of fever in children less than one year of age
Wider context from the report “4. Lack of effective application of national guidelines for assessment and investigation of fever in children less than one year of age
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations