30 Mar 2026 Ethan Michael Hanson · Prevention of Future Deaths report Warwickshire
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Concerns raised 8 Lack of practical mechanisms for communicating with neurodivergent parents View source Failure of the paediatric abdominal pain pathway to align with GIRFT structure and escalation principles View source Lack of structured local support for interpreting neurodivergent parental communication View source Lack of practical mechanisms for adapting assessment of neurodivergent children View source Lack of structured local prompts for recognising neurodivergent symptom expression View source Failure to carry critical GP information into hospital assessment View source Lack of GP awareness of referral-route implications for local hospital triage and assessment View source Absence of computerised safeguards for complete and accurate observations before pathway selection or discharge View source See 5 more concerns
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AI-generated summary
Ethan Michael Hanson · 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
Ethan was assessed by his GP and then at hospital for abdominal pain, vomiting and concern about appendicitis, but was discharged without senior review after abnormal observations and the GP’s concerns were not transferred to the hospital assessment. He later collapsed, suffered cardiac arrest, and died after imaging confirmed perforated appendicitis, peritonitis and sepsis. The principal concerns include inaccurate or incomplete observations and pain assessment, pathway and escalation arrangements that did not align with guidance, inadequate support for assessing neurodivergent children and parents, and loss of critical information during transfer from primary to hospital care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of practical mechanisms for communicating with neurodivergent parents
Wider context from the report “GIRFT guidance lacks practical mechanisms for assessing neurodivergent children and parents
The GIRFT guidance recognises that neurodivergent children may be more difficult to assess or diagnose, but it does not provide practical mechanisms for clinicians to adapt history-taking, pain assessment or communication. The guidance does not consider the risk that a neurodivergent parent may struggle to convey concern, may appear reassured when they are frightened, or may find questions and instructions confusing or intimidating. The absence of such mechanisms risks misunderstanding children’s symptoms and misinterpreting parental reassurance.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the paediatric abdominal pain pathway to align with GIRFT structure and escalation principles
Wider context from the report “Pathway design not fully aligned with national GIRFT guidance
The Trust is developing a triage model for paediatric abdominal pain. Evidence heard at inquest showed that the pathway options do not mirror the structure or escalation principles contained in the national GIRFT guidance for paediatric abdominal pain and appendicitis. This carries a risk that children with time-critical surgical conditions may not be escalated promptly or placed on an appropriate pathway.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of structured local support for interpreting neurodivergent parental communication
Wider context from the report “Local processes provide no structured support for neurodivergent children or parents
Local assessment processes do not contain structured prompts or guidance for recognising how neurodivergence may affect symptom expression or parental communication. Without a structured approach there is a risk that important clinical information will not be elicited or understood, and that apparent agreement with a discharge plan may be misinterpreted.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of practical mechanisms for adapting assessment of neurodivergent children
Wider context from the report “GIRFT guidance lacks practical mechanisms for assessing neurodivergent children and parents
The GIRFT guidance recognises that neurodivergent children may be more difficult to assess or diagnose, but it does not provide practical mechanisms for clinicians to adapt history-taking, pain assessment or communication. The guidance does not consider the risk that a neurodivergent parent may struggle to convey concern, may appear reassured when they are frightened, or may find questions and instructions confusing or intimidating. The absence of such mechanisms risks misunderstanding children’s symptoms and misinterpreting parental reassurance.
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of structured local prompts for recognising neurodivergent symptom expression
Wider context from the report “Local processes provide no structured support for neurodivergent children or parents
Local assessment processes do not contain structured prompts or guidance for recognising how neurodivergence may affect symptom expression or parental communication. Without a structured approach there is a risk that important clinical information will not be elicited or understood , and that apparent agreement with a discharge plan may be misinterpreted.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry critical GP information into hospital assessment
Wider context from the report “Critical GP information not carried forward into the hospital assessment
The GP identified the possibility of appendicitis or another serious underlying cause and recorded abnormal observations. The absence of an ambulance conveyance or written referral letter meant this information was not transferred to the hospital. As a result, Ethan entered a different clinical pathway, and the assessing clinician was unaware of the GP’s concerns. There is a wider risk that GPs may not be aware of the implications of referral route on triage and assessment in local hospitals, and that critical deterioration indicators can be lost at the point of transfer.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of GP awareness of referral-route implications for local hospital triage and assessment
Wider context from the report “Critical GP information not carried forward into the hospital assessment
The GP identified the possibility of appendicitis or another serious underlying cause and recorded abnormal observations. The absence of an ambulance conveyance or written referral letter meant this information was not transferred to the hospital. As a result, Ethan entered a different clinical pathway, and the assessing clinician was unaware of the GP’s concerns. There is a wider risk that GPs may not be aware of the implications of referral route on triage and assessment in local hospitals , and that critical deterioration indicators can be lost at the point of transfer.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of computerised safeguards for complete and accurate observations before pathway selection or discharge
Wider context from the report “Absence of computerised mandatory-field safeguards
There is no electronic system with mandatory fields or hard-stops to prevent incorrect or incomplete recording of observations or pain scores. A transposition error between oxygen saturation and temperature occurred. The absence of automated safeguards requiring complete and accurate observations before pathway selection or discharge creates a risk that clinically significant information may be overlooked. Although there is an intention to develop such a system, it is not currently in place.
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the FLACC behavioural pain assessment tool within the Clinical Assessment Unit.
Verbatim wording from the response “• The FLACC (Face, Legs, Activity, Cry, Consolability) behavioural pain assessment tool is being implemented within CAU to support more consistent and appropriate pain assessment, with full implementation anticipated by the end of June 2026.” Source location Response from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review GIRFT guidance and compile a compliant Standard Operating Procedure for paediatric abdominal pain.
Verbatim wording from the response “• The GIRFT guidance (paediatric acute abdominal pain) along with the current Trust process, is going to be reviewed to identify any gaps and actions needed” Source location Response from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
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PFD Monitor interpretation Repeat all paediatric observations before discharge and monitor compliance through routine audit.
Verbatim wording from the response “An immediate mitigating action was implemented shortly after Ethan’s death to reduce the risk of transcription errors while observations remain paper-based. This requires all paediatric observations to be repeated prior to discharge from the department, with compliance monitored through routine audit processes.” Source location Response from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
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PFD Monitor interpretation Establish neurodivergent champion roles across GEH and SWFT with a dedicated training programme.
Verbatim wording from the response “• A neurodivergent champion role is being established across GEH and SWFT, supported by a dedicated training programme. These roles will act as advocates for neurodivergent patients and their families, with implementation scheduled from July 2026.” Source location Response from George Eliot Hospital NHS Trust
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PFD Monitor interpretation Develop and disseminate coordinated communications describing GEH and SWFT services to referral partners and the public.
Verbatim wording from the response “• The Trust is developing a coordinated communications programme to clearly articulate the range of services provided across GEH and SWFT. This will be” Source location Response from George Eliot Hospital NHS Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run monthly multidisciplinary simulation sessions covering paediatric abdominal pain, neurodivergence, communication and escalation.
Verbatim wording from the response “• The learning from this case is being built into a simulation programme. The upcoming CAU simulation sessions will involve a wider multi-disciplinary group and will include scenarios around abdominal pain, including neurodivergent children, to support better recognition, communication, and escalation. These sessions are held monthly.” Source location Response from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the GIRFT paediatric abdominal pain pathway into clinical practice.
Verbatim wording from the response “The Trust recognises that the current triage model for paediatric abdominal pain does not fully align with national GIRFT guidance, creating a potential risk to timely escalation of children with serious surgical conditions. In response, immediate actions have been taken to embed the GIRFT pathway into practice, alongside targeted education, simulation training, and a formal review to update the Trust’s Standard Operating Procedure and ensure full compliance. These actions include:” Source location Response from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
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PFD Monitor interpretation Amend the paediatric casualty card to record children’s communication, sensory or behavioural needs.
Verbatim wording from the response “• The paediatric casualty card is currently being amended to include whether the parent/carer has any potential neurodiverse implications which may affect communication. This has been discussed with the Paediatric Neurodiversity & Learning Disability Lead for South Warwickshire NHS University Foundation Trust (SWFT). This has identified that the question to be placed on the casualty card should be “does this child have any communication, sensory or” Source location Response from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver and repeat targeted abdominal pain teaching for the Paediatric Team.
Verbatim wording from the response “• The Paediatric Lead delivered a teaching session on the 13 March 2026 to the Paediatric Team focusing on acute abdominal pain, using this case to highlight key learning points. The importance of following the pathway was reinforced again in the clinical huddle afterwards. This teaching session is being repeated on the 22 May 2026.” Source location Response from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
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PFD Monitor interpretation Review the Directory of Services with system partners to improve awareness of local adult and paediatric services.
Verbatim wording from the response “The Trust is undertaking a review of the Directory of Services with system partners to ensure an awareness of services delivered across all local hospitals for both adults and paediatrics. It is envisaged that this will be completed by the end of July 2026.” Source location Response from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
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PFD Monitor interpretation Develop and deliver a communications campaign promoting Hospital Passports and “All About Me” tools.
Verbatim wording from the response “• The Trust’s Communications Team is developing a formal communications plan, in partnership with the Paediatric Neurodiversity & Learning Disability Lead, to increase awareness and utilisation of Hospital Passports and “All About Me” tools. This will include a public-facing campaign, commencing in July 2026 and continuing thereafter.” Source location Response from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share GIRFT paediatric abdominal pain guidance with Emergency and Paediatric Department staff.
Verbatim wording from the response “• The pathway has been shared with all the clinical staff within the Emergency and Paediatric Department to ensure all staff are aware of the expected approach and to support a more consistent practice.” Source location Response from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Electronic Patient Record programme with enhanced validation, structured documentation and clinical safety safeguards.
Verbatim wording from the response “The Trust is currently in the implementation phase of its Electronic Patient Record (EPR) programme. As part of this work, the Trust is reviewing the critical delivery timeline to reflect issues identified within the programme to date and is therefore unable to confirm a specific go-live date at this stage, although implementation is currently anticipated in August 2027. The programme is well underway, with funding clearly identified within the Trust’s financial plans, and the Trust remains fully committed to successful delivery across both George Eliot Hospital NHS Trust and South Warwickshire University NHS Foundation Trust.” Source location Response from George Eliot Hospital NHS Trust
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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 and Clinical Assessment Unit staff access to the Integrated Care Record System for reviewing GP records.
Verbatim wording from the response “Following a multidisciplinary meeting held on 29 April 2026, it was agreed that all nursing and medical staff within the Emergency Department and Clinical Assessment Unit would be granted access to the Integrated Care Record System. This enables clinicians to review GP records, including the referring clinician’s working diagnosis and clinical considerations, prior to hospital assessment.” Source location Response from George Eliot Hospital NHS Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evaluate an electronic interface with the Directory of Services for General Practice.
Verbatim wording from the response “• The Trust will undertake an evaluation of an electronic interface with the Directory of Services for General Practice, with the aim of ensuring that the most current and accurate information is consistently accessible to all GPs. This work is scheduled for completion by the end of July 2026.” Source location Response from George Eliot Hospital NHS Trust
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PFD Monitor interpretation Provide specialist Play Specialist support to improve communication and reduce anxiety for neurodivergent children.
Verbatim wording from the response “• The Trust has a Play Specialist in post, providing specialist support to reduce anxiety and enhance communication for neurodivergent children through appropriate tools and techniques.” Source location Response from George Eliot Hospital NHS Trust
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PFD Monitor interpretation Implement the approved formal escalation pathway and supporting materials for neurodivergent patients.
Verbatim wording from the response “• A formal escalation pathway has been developed to support staff in managing neurodivergent patients, promoting increased clinical curiosity and consideration of atypical presentations. Supporting materials, including a flowchart and handbook were approved on 21 May 2026 and implementation will commence.” Source location Response from George Eliot Hospital NHS Trust
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PFD Monitor interpretation Implement PEWS documentation within Patient Track as an interim measure for paediatric observations.
Verbatim wording from the response “Until the EPR system is fully implemented, the Trust will continue to reinforce existing governance arrangements, staff training, and clinical oversight processes to minimise the risk of similar errors occurring and to ensure that observations and clinical assessments are reviewed appropriately as part of safe patient care. Additionally, the Trust will seek to implement PEWS documentation within the current electronic Patient Track for use in the Children’s Assessment Unit (CAU) as an interim measure to strengthen the recording, visibility, and escalation of paediatric observations” Source location Response from George Eliot Hospital NHS Trust
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PFD Monitor interpretation The Trust cannot confirm a specific EPR go-live date because the programme’s critical delivery timeline remains under review.
Verbatim wording from the response “The Trust is currently in the implementation phase of its Electronic Patient Record (EPR) programme. As part of this work, the Trust is reviewing the critical delivery timeline to reflect issues identified within the programme to date and is therefore unable to confirm a specific go-live date at this stage, although implementation is currently anticipated in August 2027. The programme is well underway, with funding clearly identified within the Trust’s financial plans, and the Trust remains fully committed to successful delivery across both George Eliot Hospital NHS Trust and South Warwickshire University NHS Foundation Trust.” Source location Response from George Eliot Hospital NHS Trust
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PFD Monitor interpretation Practical mechanisms in GIRFT guidance fall outside the Trust’s direct remit; the Trust will comply with any enhanced guidance GIRFT issues.
Verbatim wording from the response “The Trust acknowledges the concerns raised regarding the absence of practical mechanisms within the GIRFT guidance to support assessment and communication with neurodivergent children and their families. However, this matter falls outside the Trust’s direct remit. GIRFT has been made aware of these considerations through receipt of the Coroner’s Regulation 28 Report to Prevent Future Deaths. The Trust will, however, ensure full compliance with any enhanced or updated guidance issued by GIRFT in response to these findings.” Source location Response from George Eliot Hospital NHS Trust
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Concerns raised 6 Inconsistent coordination between specialist and non-specialist hospitals View source Inconsistent decision-making about whether patients remain in non-specialist areas or are transferred View source Lack of consistent understanding of appropriate specialist contacts and engagement timing View source Failure to clearly define patient information for specialist renal hospitals View source Lack of consistent awareness of and access to kidney transplant care guidelines and protocols View source Lack of consistent understanding of responsibility for initiating patient transfers View source See 3 more concerns
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AI-generated summary
John Frederick Doyle · 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 Frederick Doyle, a kidney transplant recipient, was admitted with rectal bleeding and a persistent cough and was later diagnosed with a severe cytomegalovirus infection after delays in testing, diagnosis and transfer to specialist care. He deteriorated to multiple organ failure and died on 30 December 2023. Concerns included unclear arrangements for contacting specialist centres, sharing information, accessing renal guidance, initiating transfers and coordinating care between specialist and non-specialist hospitals.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent coordination between specialist and non-specialist hospitals
Wider context from the report “Concern 6: Coordination Between Specialist and Non-Specialist Hospitals
There may be variation in how specialist renal hospitals engage with non-specialist hospitals that rely on their expertise , impacting collaborative efforts in patient care. Currently, there is no clear guidance on how specialist and non-specialist teams should work together effectively to ensure consistent, high-quality care for these patients.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent decision-making about whether patients remain in non-specialist areas or are transferred
Wider context from the report “Concern 5: Decision-Making for Patient Location
Considerations regarding whether patients should remain in non-specialist areas or be transferred may differ , potentially affecting consistency in care approaches.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent understanding of appropriate specialist contacts and engagement timing
Wider context from the report “Concern 1: Contacting Specialist Centres
Non-specialist medical staff may have varied understanding of the appropriate contacts and timing for engaging with specialist renal hospitals .
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly define patient information for specialist renal hospitals
Wider context from the report “Concern 2: Information Sharing with Specialist Centres
The specific patient information that non-specialist staff should provide to specialist renal hospitals may not always be clearly defined .
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent awareness of and access to kidney transplant care guidelines and protocols
Wider context from the report “Concern 3: Accessibility to Renal Care Guidelines
Non-specialist staff may experience varying levels of awareness or accessibility to guidelines and protocols for treating kidney transplant patients . This could lead to a misunderstanding of the significance and urgency of the actions recommended by specialist renal hospitals.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent understanding of responsibility for initiating patient transfers
Wider context from the report “Concern 4: Transfer Responsibility
There may be some inconsistency across non-specialist hospitals and renal hospitals in understanding who is responsible for initiating patient transfers .
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a master copy of local specialist centre contact details for switchboard.
Verbatim wording from the response “1. The first recommendation is ensuring switchboard have a master copy of local specialist centre contact details and the Trust can confirm that this action has been taken.” Source location Response 2 from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
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PFD Monitor interpretation Continue liaison with UHCW renal specialists to develop robust joint clinical guidelines.
Verbatim wording from the response “1. Contacting Specialist Centres
Following the inquest on 8 November 2024, our Consultant Governance Lead for the Medicine Directorate has continued to liaise with the Consultant Renal Specialist at UHCW to develop robust joint clinical guidelines. GEH will take every case individually as they present and will also contact the appropriate Trust where the patient is receiving their renal care. As well as guidelines from UHCW a laminated quick reference guide has been produced which contains the emergency contact numbers for renal services at UHCW. This will be displayed across the Trust.” Source location Response 1 from George Eliot Hospital NHS Trust
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PFD Monitor interpretation Discuss the new renal guidance at Directorate Governance Meetings and Trust-wide Governance meetings.
Verbatim wording from the response “Description | Action Taken
New guidelines to be made easily accessible on the Trust’s intranet | Guidelines have been developed and are currently going through the Trust’s ratification process prior to uploading on to the Trust’s intranet.
Quick reference guidelines for management of acute unwell kidney transplant recipients have been produced (a laminated poster will be displayed in clinical areas) | Posters have been shared for dissemination with the Directorate Governance Leads on the 12 December 2024. These will be discussed at the Directorate Governance Meeting.
Guidelines to be discussed at the daily doctors briefing | Information on the new guidelines and how to access them formed part of the daily brief for wards and departments from the 16 to the 20 December 2024. On the 17 December the guidelines and quick reference was e-mailed to all doctors and consultants.” Source location Response 1 from George Eliot Hospital NHS Trust
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PFD Monitor interpretation Maintain the consultant-to-consultant referral process for renal specialist advice and patient transfers.
Verbatim wording from the response “Making staff aware of the referral process asking UHCW renal staff to visit a patient on the ward | This is in the guidelines and is a consultant to consultant referral process. The process has been shared as per above.” Source location Response 1 from George Eliot Hospital NHS Trust
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PFD Monitor interpretation Complete ratification and upload the renal management guidelines to the Trust intranet.
Verbatim wording from the response “The Trust has now received management guidelines from the Renal Team at UHCW and below is a table showing what actions the Trust has taken to embed the information received.” Source location Response 1 from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the renal guidelines and quick-reference materials to Directorate Governance Leads, doctors, consultants and relevant clinical staff.
Verbatim wording from the response “Description | Action Taken
New guidelines to be made easily accessible on the Trust’s intranet | Guidelines have been developed and are currently going through the Trust’s ratification process prior to uploading on to the Trust’s intranet.
Quick reference guidelines for management of acute unwell kidney transplant recipients have been produced (a laminated poster will be displayed in clinical areas) | Posters have been shared for dissemination with the Directorate Governance Leads on the 12 December 2024. These will be discussed at the Directorate Governance Meeting.
Guidelines to be discussed at the daily doctors briefing | Information on the new guidelines and how to access them formed part of the daily brief for wards and departments from the 16 to the 20 December 2024. On the 17 December the guidelines and quick reference was e-mailed to all doctors and consultants.” Source location Response 1 from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide twice-weekly UHCW renal specialist visits for renal patients at GEH under the existing service-level agreement.
Verbatim wording from the response “4. Transfer Responsibility
Consultant to consultant clinical conversations will take place if there is a requirement to transfer the patient to the renal centre. There is a Service Level Agreement (SLA) in place for a renal specialist from UHCW to visit renal patients being cared for at a GEH, twice a week. This patient familiarisation will assist in the timely transfer process should the patient need to be relocated to the specialist centre.” Source location Response 1 from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Display laminated renal quick-reference posters across clinical areas and the Trust.
Verbatim wording from the response “Description | Action Taken
New guidelines to be made easily accessible on the Trust’s intranet | Guidelines have been developed and are currently going through the Trust’s ratification process prior to uploading on to the Trust’s intranet.
Quick reference guidelines for management of acute unwell kidney transplant recipients have been produced (a laminated poster will be displayed in clinical areas) | Posters have been shared for dissemination with the Directorate Governance Leads on the 12 December 2024. These will be discussed at the Directorate Governance Meeting.
Guidelines to be discussed at the daily doctors briefing | Information on the new guidelines and how to access them formed part of the daily brief for wards and departments from the 16 to the 20 December 2024. On the 17 December the guidelines and quick reference was e-mailed to all doctors and consultants.” Source location Response 1 from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce laminated quick-reference guidance for managing acutely unwell kidney transplant recipients.
Verbatim wording from the response “Description | Action Taken
New guidelines to be made easily accessible on the Trust’s intranet | Guidelines have been developed and are currently going through the Trust’s ratification process prior to uploading on to the Trust’s intranet.
Quick reference guidelines for management of acute unwell kidney transplant recipients have been produced (a laminated poster will be displayed in clinical areas) | Posters have been shared for dissemination with the Directorate Governance Leads on the 12 December 2024. These will be discussed at the Directorate Governance Meeting.
Guidelines to be discussed at the daily doctors briefing | Information on the new guidelines and how to access them formed part of the daily brief for wards and departments from the 16 to the 20 December 2024. On the 17 December the guidelines and quick reference was e-mailed to all doctors and consultants.” Source location Response 1 from George Eliot Hospital NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reiterate the renal guidance at the Doctors Grand Round.
Verbatim wording from the response “This will be reiterated at the Doctors Grand Round.
To be discussed at all Trust wide Governance meetings for them to share with all consultants/relevant members of staff | Shared with all Directorate Governance Leads on the 12 December 2024 for dissemination.” Source location Response 1 from George Eliot Hospital NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing consultant-to-consultant transfer arrangements and the renal specialist service-level agreement are considered sufficient for transferring patients when required.
Verbatim wording from the response “4. Transfer Responsibility
Consultant to consultant clinical conversations will take place if there is a requirement to transfer the patient to the renal centre. There is a Service Level Agreement (SLA) in place for a renal specialist from UHCW to visit renal patients being cared for at a GEH, twice a week. This patient familiarisation will assist in the timely transfer process should the patient need to be relocated to the specialist centre.” Source location Response 1 from George Eliot Hospital NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing consultant referral process is considered sufficient for deciding patient location according to clinical need.
Verbatim wording from the response “5. Decision Making For Patient Location
There is a consultant to consultant referral process in place where decisions are made on the location based on the patients clinical need.” Source location Response 1 from George Eliot Hospital NHS Trust
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15 Sep 2023 Eclipse Morrison · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 10 Failure to ensure appropriate timing and mode of delivery in high-risk pregnancies View source Unavailability of full Badgernet portal access View source Insufficient quality assurance of Badgernet entries View source Lack of clarity in interpreting Montgomery guidance and offering professional opinions on competing risks View source Insufficient technical knowledge and training for junior doctors and locums to identify serious risk factors View source Failure to ensure holistic review of relevant findings when planning timing and mode of birth View source Failure to test staff assimilation of maternity risk knowledge View source Unavailability of an implemented procedure for escalating inconclusive ultrasound measurements in high-risk pregnancies View source Failure to provide counselling supporting fully informed mode-of-delivery decisions where there is risk of shoulder dystocia View source Failure to follow existing maternity policies View source See 7 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
Eclipse Morrison · 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
Eclipse Morrison died at Nottingham City Hospital on 21 July 2021, the day after her birth, following perinatal asphyxia and complications associated with gestational diabetes, excessive fetal growth and shoulder dystocia. The principal concerns included failures to follow up missed appointments, consider and discuss appropriate timing and mode of delivery, identify risk factors during labour, and ensure adequate fetal monitoring. Further concerns related to the implementation and quality assurance of Badgernet, escalation procedures for ultrasound concerns, counselling about shoulder dystocia, and interpretation of Montgomery guidance.
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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure appropriate timing and mode of delivery in high-risk pregnancies
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these, so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of full Badgernet portal access
Wider context from the report “2. Access to Badgernet portal / full implementation of the Badgernet software
It seems that the Badgernet system is being relied on to address a number of issues which were identified in this case, and heavy reliance is being placed on a system which is not yet fully implemented . The concern remains that a critical aspect of this system, access to the portal, will not be in place until autumn 2023 at the earliest .
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient quality assurance of Badgernet entries
Wider context from the report “3. Quality Assessment
I am informed that Badgernet can easily identify fields which have not been completed and will prevent a record being closed until the field is completed, but it cannot identify the quality of any such entries . I am told that the quality checks are made on ten sets of notes per month out of an estimated 3,000 records that will be open at any one time. The concern remains that there is insufficient quality assurance in this 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in interpreting Montgomery guidance and offering professional opinions on competing risks
Wider context from the report “6. Interpretation of Montgomery
Ante-natal care is unique in that decisions have to be made for the benefit of two patients (the mother and the baby) and the treatment options for each may, as in this case have competing risks and benefits. In addition, in ante-natal care, the circumstances may change and action may need to be taken very quickly.
On the basis of evidence given at the inquest, there seems to be a lack of clarity as to the way in which Montgomery guidance are interpreted. It was acknowledged in evidence that parents often want a steer as to the best/safest course of action and that may require medical professionals to express opinions as to the weight to be placed on different risk factors. In some cases, parents may prefer to rely on the viewpoint of an experienced medical professional. It seems that medical professionals do not feel they can offer this assistance as it might be interpreted as trying to impose their opinion on the parent. The way in which Montgomery is interpreted and the extent to which medical professionals can offer an opinion is of wider concern than just the actions of those at GEH and should be considered by those who produce the guidance and deliver training to medical professionals.
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient technical knowledge and training for junior doctors and locums to identify serious risk factors
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these , so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure holistic review of relevant findings when planning timing and mode of birth
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these, so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to test staff assimilation of maternity risk knowledge
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these, so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an implemented procedure for escalating inconclusive ultrasound measurements in high-risk pregnancies
Wider context from the report “4. Procedure for escalating concerns arising out of Ultrasound Scans (USS)
I understand that the procedure for escalating concerns arising out of a USS where it is not possible to obtain an accurate measurement in a high-risk pregnancy is currently under review . I am told that the new policy is not in place . The concern remains that no date has been set for its implementation.
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide counselling supporting fully informed mode-of-delivery decisions where there is risk of shoulder dystocia
Wider context from the report “5. Counselling for mothers at increased risk of shoulder dystocia
I have not seen any indication that all mothers identified to have an increased chance of shoulder dystocia now receive counselling regarding the risks and benefits associated with vaginal birth or CS. Assisting mothers to understand the implications of risks they face is fundamental to supporting them to make fully informed decisions, in accordance with Montgomery. The concern remains that there is no clear plan in place to ensure mothers receive the support they require to make fully informed decisions in relation to mode of delivery where there is risk of shoulder dystocia.
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow existing maternity policies
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these, so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” Open source report
11 Jan 2023 Carol Ann Welch · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 7 Failure to assess doctors’ understanding of appropriate clinical guidelines View source Lack of familiarity with guidance requiring consultant discussion of unexpected returns within 72 hours View source Lack of checks that staff have considered and understood safety material View source Failure to ensure all doctors receive learning-point discussions View source Failure to give patient-critical guidance appropriate prominence View source Failure to embed patient-safety learning and convey it to new senior team members View source Lack of awareness of subarachnoid haemorrhage masquerading as migraine and possible neurological findings View source See 4 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
Carol Ann Welch · 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
Carol Ann Welch became unwell with symptoms initially diagnosed as migraine, returned to the emergency department with changed symptoms, and was discharged without further investigation. She suffered a cardiac arrest on 30 April 2022 and died on 1 May 2022 after an undiagnosed cerebral aneurysm and subsequent spontaneous subarachnoid haemorrhage. Concerns included failure to investigate possible neurological findings, failure to follow guidance on consultant review after an unexpected return within 72 hours, and uncertainty about how relevant learning and guidance would be embedded, assessed and communicated across the medical team.
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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess doctors’ understanding of appropriate clinical guidelines
Wider context from the report “(2) It was stated that the middle grade doctor who discharged Carol at her second attendance on 28 April 2022 was trained at a reputable institute overseas where Royal College guidance was not applicable. He had undergone a significant period of training and familiarisation and assessment at GEH, but it was not clear as to the way in which his understanding and appreciation of the appropriate guidelines had been assessed .
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of familiarity with guidance requiring consultant discussion of unexpected returns within 72 hours
Wider context from the report “(1) The subsequent investigation by GEH highlighted two areas which needed addressing:
• The need to raise awareness of subarachnoid haemorrhage masquerading as a migraine and the need to investigate possible neurological findings. This had been done by means of discussions in meetings and a poster displayed in a staff area.
• Doctors were not familiar with the Royal College Guidance that there is a need to discuss with a consultant, all patients who unexpectedly return within 72 hours of discharge from the emergency department . This had been done by circulating an aide memoire to be given to those in training and existing members of the department.
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of checks that staff have considered and understood safety material
Wider context from the report “(6) Although staff members would have the opportunity of accessing the material, there did not appear to be any checks to ensure that staff members had considered and understood the material provided .
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure all doctors receive learning-point discussions
Wider context from the report “(4) It did not appear that all doctors would have been present at meetings where the learning points were discussed .
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to give patient-critical guidance appropriate prominence
Wider context from the report “(3) The document (described as an aide memoire) which notified all doctors of the Royal College Guidance referred to other matters such as punctuality and staff sick leave. Matters critical to patient care were not clearly identified and given appropriate prominence .
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to embed patient-safety learning and convey it to new senior team members
Wider context from the report “(5) The evidence made it clear that the individuals concerned had subsequently undergone appropriate training and reflection to avoid any recurrence. However, it was less clear how either learning point identified would be embedded in the team as a whole and conveyed to new members joining the team , particularly those joining the team at a more senior level, who would not previously have operated within the 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of subarachnoid haemorrhage masquerading as migraine and possible neurological findings
Wider context from the report “(1) The subsequent investigation by GEH highlighted two areas which needed addressing:
• The need to raise awareness of subarachnoid haemorrhage masquerading as a migraine and the need to investigate possible neurological findings . This had been done by means of discussions in meetings and a poster displayed in a staff area.
• Doctors were not familiar with the Royal College Guidance that there is a need to discuss with a consultant, all patients who unexpectedly return within 72 hours of discharge from the emergency department. This had been done by circulating an aide memoire to be given to those in training and existing members of the department.
” 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 Review and revise the clinical aid memoire to place clinically essential information first.
Verbatim wording from the response “The aid memoire provided to the court was an example of key learning that was shared as part of a comprehensive induction and following learning from Mrs Welch’s case. The aid memoire captured essential information and was not in order of priority. In consideration of your comments regarding the aid memoire, this has been reviewed and revised to ensure all clinically essential information is at the top.” Source location Response from George Eliot Hospital
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 shared server and intranet locations so staff can access incident-learning reports and written materials.
Verbatim wording from the response “It is recognised that if an individual wishes to access reports or written material on learning in their own time that at the time of this incident these documents were kept within a restricted folder on our Trust server. To ensure that meeting reports are accessible to all staff for the purpose of learning the directorate is exploring a shared drive on its server and a shared area on its staff intranet platform, so these are easily accessible as the documents do not hold any patient identifiable details.” Source location Response from George Eliot Hospital
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 Work with Information Technology to add a 72-hour reattendance alert requiring consultant advice before discharge.
Verbatim wording from the response “The Trust has, however, noted that the middle grade doctor in question did not follow the appropriate guidance of referring to a consultant if a patient returns to the department within 72 hours with the same clinical condition. The Trust is currently working with its Information Technology Department to add an alert to the Clinical Portal used by UEC to flag/highlight if the patient reattends within 72 hours and mandate that the doctor should seek advice from a consultant prior to discharging the patient from the department. We believe this additional safety measure would prevent future harm in this group of patients who are at higher risk.” Source location Response from George Eliot Hospital
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 Audit patients reattending within 72 hours for consultant referral before discharge and share the findings within UEC and at Trust-wide Audit Day.
Verbatim wording from the response “UEC are in the process of conducting an audit to review patients that have reattended within 72 hours to see whether they were referred to a consultant prior to discharge. The outcome of this review will be shared within UEC and will also be presented at the Trust Wide Audit Day.” Source location Response from George Eliot Hospital
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 Requiring every clinician to confirm reading each guideline is considered impractical because of the high volume and risk of becoming a tick-box exercise.
Verbatim wording from the response “have Royal College Guidelines and NICE Guidelines applicable. Hyperlinks to both of these websites are easily accessible on the department’s bespoke intranet page. The Trust has proactively considered asking every clinician to sign to confirm that they have read each guideline but at this time believe that due to the high volume of applicable guidelines it would be impractical to achieve and worse still it could turn into a tick box exercise.” Source location Response from George Eliot Hospital
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 Clinical supervision, monthly reviews and annual appraisals are considered sufficient to monitor doctors’ performance, support and training needs.
Verbatim wording from the response “Each junior and middle grade doctor within the Trust has an assigned Clinical Supervisor who is appropriately trained and responsible for overseeing the junior/middle grade doctors’ clinical work. The Clinical Supervisors at the Trust are always at a consultant level. The Clinical Supervisors have monthly meetings where they discuss each doctor to review their clinical work, ascertain how well they are doing and whether they require additional support or training in certain fields. In addition, all junior and middle grade doctors also have appraisals undertaken by a trained Appraiser on an annual basis where their performance including training is monitored to ensure they are compliant.” Source location Response from George Eliot Hospital
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 Overseas-qualified doctors undergo Royal College accreditation, including assessment of familiarity with relevant guidance, on the same basis as UK-trained doctors.
Verbatim wording from the response “When the Trust receives an application from a doctor our People and Recruitment Department will check the official GMC registration to ensure the doctor is appropriately registered and holds the relevant qualifications and license to practice in the UK. The doctor in Mrs Welch’s case was registered with the GMC in April 2020. In addition, this doctor became a member of the Royal College of Emergency Medicine before they started working at this Trust in September 2020. Accordingly, the doctor will have been assessed as competent by the Royal College as part of their registration and accreditation process in exactly the same way a UK trained doctor would be assessed. This accreditation includes an assessment of familiarity with relevant Royal College guidance.” Source location Response from George Eliot Hospital
Open published response
15 Feb 2016 Eileen Annie Thompson · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 2 Inaccessibility of inner-wheel locking mechanisms when beds are placed against walls View source Failure to lock the inner wheels of beds 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
Eileen Annie Thompson · 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
Eileen Annie Thompson, who had dementia, fell between her bed and a wall after the bed moved and sustained serious head injuries. She died shortly after admission to hospital. The concerns were that the bed’s inner wheels were not locked because their locking mechanisms were inaccessible against the wall, creating a risk of recurrence for other service users.
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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of inner-wheel locking mechanisms when beds are placed against walls
Wider context from the report “(1) The bed was able to move from the wall because the two inner wheels were not locked.
(2) The locking mechanism for the inner wheels was not easily accessible when the bed was placed against a wall .
(3) There is risk of recurrence in respect of service users who are provided with this type of bed when the bed is placed against a wall.
” 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 George Eliot Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to lock the inner wheels of beds
Wider context from the report “(1) The bed was able to move from the wall because the two inner wheels were not locked .
(2) The locking mechanism for the inner wheels was not easily accessible when the bed was placed against a wall.
(3) There is risk of recurrence in respect of service users who are provided with this type of bed when the bed is placed against a wall.
” 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