Concerns raised 4 Poor vascular ward communication when post-operative concerns are raised View source Failure of the community team to consistently record key clinical assessment information View source Inconsistency between hospital and community teams about post-discharge procedures and points of access View source Absence of documented discharge advice on points of access for concerns or complications View source See 1 more concern
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
William Nichols · 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
William Nichols underwent a femoral endarterectomy and developed a deep patch infection, followed by a catastrophic haemorrhage from the right femoral artery. The report identifies concerns about inconsistent communication between hospital and community teams, insufficient documented discharge advice, poor communication about bleeding concerns, and inadequate community-team record keeping.
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 Gateshead Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor vascular ward communication when post-operative concerns are raised
Wider context from the report “(3) Poor communication from the vascular ward when concerns were raised post-operatively , particularly the concern about bleeding in the wound 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 Gateshead Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the community team to consistently record key clinical assessment information
Wider context from the report “(4) Poor record keeping from the community team which meant that key clinical assessment information was not consistently recorded .
” 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 Gateshead Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistency between hospital and community teams about post-discharge procedures and points of access
Wider context from the report “(1) Inconsistency in understanding between the hospital and the community teams as to the procedure to follow post discharge from vascular surgery and the points of access in the event of concern or complication (including suspected infection, or bleeding).
” 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 Gateshead Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of documented discharge advice on points of access for concerns or complications
Wider context from the report “(2) The absence of provision of documented advice to patients on discharge as to points of access in the event of concern or complication (including suspected infection or bleeding).
” 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 Make changes to electronic clinical-record proformas to strengthen record keeping and capture accurate, relevant clinical information.
Verbatim wording from the response “As referred to in the inquest, at the time of Mr Nichols' death, the Trust had only very recently moved to a fully electronic records system. This system is now fully embedded and since Mr Nichols' death, 4 years ago, numerous changes have been made to the electronic proformas to strengthen record keeping and capture accurate and key clinical information.” Source location Response from Gateshead 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 Liaise with Newcastle Trust to confirm the correct procedure for community teams to contact vascular services about post-discharge concerns.
Verbatim wording from the response “As heard at the inquest and in our subsequent submissions made by letter in July 2023, the Trust followed the correct procedure of contacting the ward at the Newcastle Trust, when the Community team noted the presence of fresh blood and spoke with a Specialist Vascular Nurse from the Newcastle Trust for advice, who in turn spoke with a medic from the Vascular Team. Following the inquest, the Trust liaised with the Newcastle Trust, to ensure that this remains the correct procedure for contacting their team and they have confirmed it does.” Source location Response from Gateshead 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 Share inquest findings with District Nurses, reiterating ward contact routes, contact-information access, and warning signs after femoral endarterectomy.
Verbatim wording from the response “Following the inquest and collaboration with the Newcastle Trust, the findings of the inquest have been shared with our District Nurses, to reiterate the process they already follow, including:” Source location Response from Gateshead 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 professional information leaflet for District Nurses covering post-operative risks, escalation requirements, and intervention following femoral endarterectomy.
Verbatim wording from the response “We have also been liaising with the Newcastle Trust and developed a professional information leaflet for District Nurses which outlines what they should be aware of in relation to this specific procedure in the post operative period and what requires escalation and intervention. We understand you have received this from Newcastle Trust. We have therefore done all we can as a Trust in relation to this concern.” Source location Response from Gateshead Health NHS Foundation Trust
Open published response
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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 disputes that key clinical information was inconsistently recorded, stating that information was recorded and concerns were appropriately escalated.
Verbatim wording from the response “Having reviewed the evidence, we are unable to ascertain where this concern arises from, which makes it difficult to respond directly. However, we would be more than willing to address this further if more detail about the concern could be provided.” Source location Response from Gateshead Health NHS Foundation Trust
Open published response
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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 procedures and collaboration with Newcastle Trust adequately address post-discharge communication and escalation following vascular surgery.
Verbatim wording from the response “It is the Trust's position that we have already addressed this concern (and had done so by the time of the inquest hearing) and therefore it is unclear if this concern is directed at us, but in the event that it is, we would respond as follows.” Source location Response from Gateshead Health NHS Foundation Trust
Open published response
Concerns raised 9 Failure to refer women with elevated maternal or fetal growth indicators for Consultant Obstetric care View source Failure to prepare a risk-based birth plan with appropriate environment and skilled staff for macrosomic babies View source Failure to red-flag significant maternal and fetal growth findings in records View source Failure to plan and counsel on timing and mode of delivery for suspected larger babies View source Failure to assess maternal and fetal risk before selecting a Birthing Pool delivery View source Failure to review and interpret antenatal records and Growth Chart on labour admission View source Failure to identify pregnancy status on glucose tolerance test requests View source Inability of nursing and medical staff to interpret Growth Charts and recognise referral triggers View source Lack of clear and consistently applied Trust guidance for managing larger babies View source See 6 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
ARCHIE RAY GRIEVES · 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
Archie Ray Grieves was born on 24 May 2017 following a complicated delivery involving shoulder dystocia. He initially showed no signs of life, later showed signs of life, and died a short time after being taken to the special care baby unit. The report identified an avoidable neonatal death, with an eight-minute delay in delivering his body after his head and missed opportunities during antenatal care and delivery to identify risks and plan a safe birth.
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 Gateshead Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer women with elevated maternal or fetal growth indicators for Consultant Obstetric care
Wider context from the report “4. The mother was not referred to a Consultant lead Obstetric examination and assessment when issues and concerns would have been identified both as to her presentational weight and the potential consequential size of the baby.
5. A subsequent test apparently indicated no diabetes and a determination that the ante natal care should follow a normal pathway
6. At the 34th week fundal size continued to identify the baby’s development as outwith the 95th centile and consequently on the basis of the Trust’s own guidelines this mother should have been referred also to Consultant Obstetric care .
” 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 Gateshead Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prepare a risk-based birth plan with appropriate environment and skilled staff for macrosomic babies
Wider context from the report “14.No risk assessment was made preparatory to the delivery of a macroscop ic baby and the heightened risk of shoulder dystocia
15.No plan was prepared guiding or assistance sought to facilitate a safe birth in a safe environment and with the appropriate level of skilled staff on hand or available
” 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 Gateshead Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to red-flag significant maternal and fetal growth findings in records
Wider context from the report “23.The missed opportunities in this matter would have been avoided if significant findings had been “red flagged” within mother’s records . A significant finding being something which is potentially likely to impact on the management and care of the patient at some stage during their journey and more particularly one identified as factors in the policies and practices of the Trust determined to ensure the safe care of the patient and in this case mother and baby.
24.Such red flags in this matter would and should have highlighted :
a) A heightened BMI
b) A Fundal height above and outwith the gestational norm
25.As an added aid to safe management and care such “red flags” should cross reference specific Policies/protocols where such issues contra- indicate certain strategies (birthing pools and increased BMI large baby) or alert for protective planning and preparation
26.The fact that the Growth Chart in this matter :-
a) demonstrated the baby to be large for his gestational age and
b) there was an apparent lack of understanding appreciation /conflict as to the significance of The Chart as well as
c) an inability to interpret The Chart by nursing and medical staff and
d) more importantly a lack of awareness that such a measure should in accordance with established Trust policy have lead to a Obstetric referral and consultation,
together leads to :-
” 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 Gateshead Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to plan and counsel on timing and mode of delivery for suspected larger babies
Wider context from the report “8. No additional planning for pre delivery/delivery was engaged and this mother was continued on a normal pathway towards delivery apparently planned between the 40th and 42nd week.
9. In the absence of Obstetric care effective planning opportunities were missed to consult and counsel this mother on the mode and time of delivery . In particular no consideration was given to the possibility of an induced or caesarean birth or delivery of this child at the 37th/38th week avoiding increases in baby’s weight and recognisable risks at the time of delivery of a larger baby.
” 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 Gateshead Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess maternal and fetal risk before selecting a Birthing Pool delivery
Wider context from the report “11.Specifically during the period from 1.30 pm to 6.30 pm, in the absence of any meaningful interrogation of her records the assessment of the mother on presentation in the delivery suite failed to identify any risk she presented in view of her personal bodymass or the size of her baby . It was determined it was appropriate that she deliver in the Birthing Pool. The only considerations as to Pool use were practical considerations around availability, staffing and an adjacent delivery room.
12.As a consequence of the lack of any alert to the risks that this lady presented no consideration was given to the potential risks identified within the Trusts own protocols relevant in the case of this lady and her child.
13.An opportunity was missed to guide the mother away from a pool birth because of those risks and to an alternative method of delivery with appropriate levels of analgesic support commensurate with her needs and anxiety
” 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 Gateshead Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review and interpret antenatal records and Growth Chart on labour admission
Wider context from the report “10.On presentation on the 24th May 2017 in labour this mother was received within the Delivery unit as a low risk delivery and no review was undertaken of her earlier management and care either because of the assumption of the appropriateness of her ante natal care together with a conclusion which identified her as simply low risk and/or because there was no meaningful interrogation of her records . In particular the significance of the Growth Chart present within those records with its all too apparent fundal height measurement was misunderstood/misinterpreted or overlooked as to its relevance.
” 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 Gateshead Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify pregnancy status on glucose tolerance test requests
Wider context from the report “3. A glucose tolerance test was commissioned. The test request did not identify the patient was pregnant. The result was consequently wrongly interpreted as normal.
” 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 Gateshead Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inability of nursing and medical staff to interpret Growth Charts and recognise referral triggers
Wider context from the report “23.The missed opportunities in this matter would have been avoided if significant findings had been “red flagged” within mother’s records. A significant finding being something which is potentially likely to impact on the management and care of the patient at some stage during their journey and more particularly one identified as factors in the policies and practices of the Trust determined to ensure the safe care of the patient and in this case mother and baby.
24.Such red flags in this matter would and should have highlighted :
a) A heightened BMI
b) A Fundal height above and outwith the gestational norm
25.As an added aid to safe management and care such “red flags” should cross reference specific Policies/protocols where such issues contra- indicate certain strategies (birthing pools and increased BMI large baby) or alert for protective planning and preparation
26.The fact that the Growth Chart in this matter :-
a) demonstrated the baby to be large for his gestational age and
b) there was an apparent lack of understanding appreciation /conflict as to the significance of The Chart as well as
c) an inability to interpret The Chart by nursing and medical staff and
d) more importantly a lack of awareness that such a measure should in accordance with established Trust policy have lead to a Obstetric referral and consultation ,
together leads to :-
” 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 Gateshead Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and consistently applied Trust guidance for managing larger babies
Wider context from the report “16.Further evidence adduced indicated there was an apparent misunderstanding and/or misinterpretation even level of conflict amongst Obstetric Consultants as to the Trust’s own guidance on potential large baby development risks and the alternative strategies to be followed and in a timely manner for the safe delivery of such children.
17.Evidence was received that large babies were not identified as such a great concern as small babies, that mothers of the latter would be monitored and advised and quite properly so but larger babies size being more indicative of the healthy presentation and more positive outcome, were accordingly considered less at risk
18.Obstetric approach differed depending on the Consultants personal policy and consequently a more cohesive leadership Departmental approach was potentially missing
19.In addition it was acknowledged that there was a study nationally , currently being undertaken with reference to the management of larger babies and their birth. At the time of this matter and indeed now the outcome of that study was still awaited and no definitive guide appears to exist within the Trust .
20.The consequences of this lack of cohesive policy lends itself to a lack of clear understanding and consistent approach which should be the guideline in all cases and for the benefit of all staff both medical and nursing.
” Open source report
16 Mar 2017 Derek Wynne Turnbull · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 1 Delay in summoning an ambulance for cases to be stepped up to hospital 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
Derek Wynne Turnbull · 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
Derek Wynne Turnbull, a resident at the ICAR Unit with a recognised risk of falls and taking Warfarin, suffered an unwitnessed fall with facial injuries on 9 August 2016 and was taken to hospital after an ambulance was summoned 63 minutes after he was found. He was diagnosed with a large acute-on-chronic subdural haemorrhage and died at Sunderland Royal Hospital on 10 August 2016; the principal concern was the delay in summoning an ambulance despite the known risk factors and head injury.
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 Gateshead Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in summoning an ambulance for cases to be stepped up to hospital
Wider context from the report “Mr Derek Wynne Turnbull had a known history of falls, was on Warfarin and had sustained an obvious head injury after an unwitnessed fall, yet it took from 03:15am to 04:18am to summons an ambulance by a 999 call in a case that was to be “stepped up” to hospital in any event . There was no purpose in waiting, given the known scenario.
In Mr Turnbull’s case the delay may not have caused or contributed to his death, but in other cases the opportunity for earlier review at the hospital ought to be taken .
Policies, procedures and protocols may need to be reviewed in order to ensure that in those cases that are to be stepped up, that the action is taken immediately.
” 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