Frimley Park Hospital

Private and voluntary organisations · Multi-service care provider

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First report 20 Mar 2014•Latest report 3 Jun 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports: 6
Published responses: 17%
Concerns addressed: 2
Stated actions: 5

Concerns and recipient responses

Statements from Frimley Park Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

3 Jun2024
Surrey
Concerns raised5
1. Insufficient staffing in the dietetics department to address patients' dietetic needs
2. Insufficient training of agency staff to record medical care on the ward computer system
3. Staff lacking knowledge of techniques for repositioning patients with multiple injuries
1. Failure to identify unreleased Fortisip orders on the hospital computer system
2. Staff lacking training to support and handle patients in pain who refuse repositioning
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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 Mar2022
Surrey
Concerns raised8
1. Insufficient discharge advice for potentially time-critical complaints
2. Failure to account for the limited sensitivity of upright chest X-rays when excluding perforation
3. Failure to recognise signs of sepsis
1. Failure to perform further abdominal examination before discharge
2. Failure to undertake second-line investigation of suspected perforation
3. Failure to complete investigation of suspected bowel perforation
4. Failure to seek surgical opinion for suspected post-surgical symptoms
5. Failure to recognise post-surgical pain or sickness as indicators of serious complications
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 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 Nov2021
Berkshire
Concerns raised2
1. Shortage of nursing staff
2. Reliance on agency nursing staff
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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
14 Oct2016
Surrey
Concerns raised8
1. Incoherent and inconsistent sedation practice for catheter laboratory procedures
2. Inappropriate use of sedation for cardiac electrophysiological procedures
3. Lack of a sedation policy for cardiac electrophysiological procedures
1. Lack of an action plan for obtaining assistance during airway loss or difficulty placing a pacemaker wire
2. Lack of regular training in the safe and appropriate use of anxiolytics and analgesics
3. Lack of an action plan for patients who do not tolerate the procedure
4. Lack of understanding of required observations during the procedure
5. Lack of knowledge of the policy for safe sedation outside the operating theatre environment
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
26 Nov2014
Surrey
Concerns raised2
1. Failure to seek appropriate senior medical advice before administering medication to a patient with a known allergy
2. Failure to obtain informed consent for administering medication to which a patient has a known allergy
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 Mar2014
Surrey
Concerns raised5
1. Lack of effective supervision of non-career grade paediatricians without previous experience
2. Lack of independent consultant assessment of paediatric admissions outside normal working hours
3. Failure to acknowledge or act on parent concerns
1. Lack of consultant supervision of out-of-hours on-call paediatric trainees
2. Lack of effective application of national guidelines for assessment and investigation of fever in children less than one year of age
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

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised5

Insufficient staffing in the dietetics department to address patients' dietetic needs

Insufficient training of agency staff to record medical care on the ward computer system

Staff lacking knowledge of techniques for repositioning patients with multiple injuries

Failure to identify unreleased Fortisip orders on the hospital computer system

Staff lacking training to support and handle patients in pain who refuse repositioning

Concerns raised8

Insufficient discharge advice for potentially time-critical complaints

Failure to account for the limited sensitivity of upright chest X-rays when excluding perforation

Failure to recognise signs of sepsis

Failure to perform further abdominal examination before discharge

Failure to undertake second-line investigation of suspected perforation

Failure to complete investigation of suspected bowel perforation

Failure to seek surgical opinion for suspected post-surgical symptoms

Failure to recognise post-surgical pain or sickness as indicators of serious complications

Concerns raised2

Shortage of nursing staff

Reliance on agency nursing staff

Concerns raised8

Incoherent and inconsistent sedation practice for catheter laboratory procedures

Inappropriate use of sedation for cardiac electrophysiological procedures

Lack of a sedation policy for cardiac electrophysiological procedures

Lack of an action plan for obtaining assistance during airway loss or difficulty placing a pacemaker wire

Lack of regular training in the safe and appropriate use of anxiolytics and analgesics

Lack of an action plan for patients who do not tolerate the procedure

Lack of understanding of required observations during the procedure

Lack of knowledge of the policy for safe sedation outside the operating theatre environment

Concerns raised2

Failure to seek appropriate senior medical advice before administering medication to a patient with a known allergy

Failure to obtain informed consent for administering medication to which a patient has a known allergy

Concerns raised5

Lack of effective supervision of non-career grade paediatricians without previous experience

Lack of independent consultant assessment of paediatric admissions outside normal working hours

Failure to acknowledge or act on parent concerns

Lack of consultant supervision of out-of-hours on-call paediatric trainees

Lack of effective application of national guidelines for assessment and investigation of fever in children less than one year of age