31 Jan 2023 Donald Charles Brown · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 4 Expectation for reporting all scans within an hour View source Significant understaffing of the hospital Radiology department View source National shortage of radiology trainee posts View source Delay in appointing call handlers to triage calls 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
Donald Charles Brown · 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
Donald Charles Brown, an 87-year-old man, suffered a fall at home and was later found to have a displaced C2 vertebral fracture with spinal cord compression that had been visible on the initial CT but was not reported. He subsequently developed swallowing difficulties and aspiration pneumonia before dying in hospital; concerns included significant radiology understaffing, a national shortage of radiology trainee posts, expectations for rapid scan reporting, and delayed appointment of call handlers due to cost.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Expectation for reporting all scans within an hour
Wider context from the report “3. The expectation that the reporting of all scans including non urgent, will be done within an hour .
” 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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Significant understaffing of the hospital Radiology department
Wider context from the report “1. The significant understaffing of the Radiology department at the hospital .
” 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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation National shortage of radiology trainee posts
Wider context from the report “2. The national shortage of radiology trainee posts .
” 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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in appointing call handlers to triage calls
Wider context from the report “4. The appointment of call handlers to triage calls to reduce the demands on the radiologists’ time has been delayed due to cost .
” 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 Produce frequently asked questions for radiography staff to reduce interruptions to radiology sessions.
Verbatim wording from the response “The service has a number of initiatives in hand to reduce the administrative burden on radiologists including but not limited to” Source location Response from Gloucestershire 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 Train radiographers to vet scans under predefined radiologist protocols.
Verbatim wording from the response “The service has a number of initiatives in hand to reduce the administrative burden on radiologists including but not limited to” Source location Response from Gloucestershire 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 Secure an additional radiology trainee post commencing in August 2023.
Verbatim wording from the response “The allocation of trainees is the responsibility of Health Education England. Concerns have been expressed about the distribution of trainees nationally, reflecting the bias to distribution to London. HEE is in the process of redistributing a proportion of these trainees and Gloucestershire Hospitals has been successful in securing an additional (eighth) trainee from the Severn Deanery commencing in post in August 2023. Additionally, we are aiming to create a fellowship spot (post training role) for further applicants.” Source location Response from Gloucestershire Hospital
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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 Investigate an artificial intelligence tool to improve triage between urgent and less urgent scans.
Verbatim wording from the response “The service has a number of initiatives in hand to reduce the administrative burden on radiologists including but not limited to” Source location Response from Gloucestershire 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 Recruit three inpatient navigators to undertake call triage and reduce radiologists’ administrative burden.
Verbatim wording from the response “The service has a number of initiatives in hand to reduce the administrative burden on radiologists including but not limited to” Source location Response from Gloucestershire 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 The radiology department is not significantly understaffed, with only one vacancy and a vacancy rate below the national rate.
Verbatim wording from the response “1. The significant understaffing of the radiology department at the hospital” Source location Response from Gloucestershire 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 Not all scans require reporting within one hour; national standards set different timescales according to clinical urgency.
Verbatim wording from the response “3. The expectation that the reporting of all scans including non-urgent, will be done within one hour” Source location Response from Gloucestershire 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 Health Education England is responsible for allocating radiology trainee posts nationally.
Verbatim wording from the response “2. The national shortage of radiology trainee posts” Source location Response from Gloucestershire Hospital
Open published response
17 Oct 2019 Elisa Fuller · Prevention of Future Deaths report Gloucestershire
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Concerns raised 2 Insufficient support and systems for junior midwives and junior doctors to escalate concerns to senior colleagues View source Insufficient understanding of the need to retain placentas post delivery for a specified period before disposal View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 9
Action
Debrief midwifery staff to explore and understand barriers to escalation.
Stated completedThe respondent said that this action was complete when they made their response on 17 October 2019. View source
Action
Deliver mandatory midwife update training incorporating lessons from incidents and expectations for escalating concerns.
Stated completedThe respondent said that this action was complete when they made their response on 17 October 2019. View source
Action
Deliver PROMPT multi-professional training covering human factors, resilience, teamwork and effective communication relevant to escalation.
Stated completedThe respondent said that this action was complete when they made their response on 17 October 2019. View source
Action
Retain and identify every placenta for 24 hours after birth, supported by a new procedure, teaching sessions, guidance and signage.
Stated completedThe respondent said that this action was complete when they made their response on 17 October 2019. View source
Action
Provide rotation-day training for new, returning and transitioning midwives, including escalation, communication, assertiveness and professional behaviour.
Stated completedThe respondent said that this action was complete when they made their response on 17 October 2019. View source
Action
Use the SBAR structured referral tool to formalise escalation reasons and patient-review plans for midwives and doctors.
Stated completedThe respondent said that this action was complete when they made their response on 17 October 2019. View source
Action
Hold a staff event addressing workplace factors affecting performance, including team roles, respectful communication and support for less experienced staff.
Stated completedThe respondent said that this action was complete when they made their response on 17 October 2019. View source
Action
Launch the updated Newborn Early Warning Trigger and Track chart in all relevant clinical areas.
Stated plannedThe respondent said that this action was planned when they made their response on 17 October 2019. View source
Action
Hold a Trust Safety Department Black Box learning event to explore barriers to escalation and improve multiprofessional learning from incidents.
Stated plannedThe respondent said that this action was planned when they made their response on 17 October 2019. View source See 6 more actions
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AI-generated summary
Elisa Fuller · 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
Elisa Fuller was delivered by elective Caesarean section at 36 weeks gestation on 9 February 2018 and later developed respiratory distress. During intubation, she suffered an idiosyncratic reaction to suxamethonium that triggered cardiac arrest, and resuscitation was unsuccessful. Concerns related to the escalation of concerns by junior staff and understanding of the need to retain placentas after delivery for a specified period.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient support and systems for junior midwives and junior doctors to escalate concerns to senior colleagues
Wider context from the report “Although I acknowledge that the Trust have put in place systems to address the second concern. In relation to the first concern, further training has been put in place. However there remains work to be done.
(1) Whether there is appropriate support and systems in place to encourage Junior Midwives and Junior Doctors to escalate any concerns they have to more Senior Colleagues ,
(2) Whether there is sufficient understanding of the need to retain placentas post delivery for a specified time period prior to disposal.
” 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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of the need to retain placentas post delivery for a specified period before disposal
Wider context from the report “Although I acknowledge that the Trust have put in place systems to address the second concern. In relation to the first concern, further training has been put in place. However there remains work to be done.
(1) Whether there is appropriate support and systems in place to encourage Junior Midwives and Junior Doctors to escalate any concerns they have to more Senior Colleagues,
(2) Whether there is sufficient understanding of the need to retain placentas post delivery for a specified time period prior to disposal .
” 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 Debrief midwifery staff to explore and understand barriers to escalation.
Verbatim wording from the response “Finally, I can also add that as a result of the inquest into Elisa’s death, the following additional review and learning has taken place, for the clinical staff involved, and for any interested colleagues:” Source location 2019-0481-Response-by-Gloucestershire-Hospitals-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mandatory midwife update training incorporating lessons from incidents and expectations for escalating concerns.
Verbatim wording from the response “I. Mandatory Update day - Midwives” Source location 2019-0481-Response-by-Gloucestershire-Hospitals-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver PROMPT multi-professional training covering human factors, resilience, teamwork and effective communication relevant to escalation.
Verbatim wording from the response “IV. Practical Obstetric Multi-Professional Training – PROMPT’ - Midwives and Doctors” Source location 2019-0481-Response-by-Gloucestershire-Hospitals-NHS-Trust
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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 Retain and identify every placenta for 24 hours after birth, supported by a new procedure, teaching sessions, guidance and signage.
Verbatim wording from the response “However, in response to the evidence heard at the inquest from the pathologist that his determination of the cause of death was considerably limited by the absence of the placenta, the Trust has revised its policy on retention of placentas so that all placentas are retained for 24 hours after birth, and are sufficiently identified so that they can be reliably retrieved in the event that there are any subsequent adverse clinical events affecting the baby.” Source location 2019-0481-Response-by-Gloucestershire-Hospitals-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide rotation-day training for new, returning and transitioning midwives, including escalation, communication, assertiveness and professional behaviour.
Verbatim wording from the response “III. Rotation Day programme - Midwives” Source location 2019-0481-Response-by-Gloucestershire-Hospitals-NHS-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 Use the SBAR structured referral tool to formalise escalation reasons and patient-review plans for midwives and doctors.
Verbatim wording from the response “II. SBAR referral tool - Midwives and Doctors” Source location 2019-0481-Response-by-Gloucestershire-Hospitals-NHS-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 Hold a staff event addressing workplace factors affecting performance, including team roles, respectful communication and support for less experienced staff.
Verbatim wording from the response “Finally, I can also add that as a result of the inquest into Elisa’s death, the following additional review and learning has taken place, for the clinical staff involved, and for any interested colleagues:” Source location 2019-0481-Response-by-Gloucestershire-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch the updated Newborn Early Warning Trigger and Track chart in all relevant clinical areas.
Verbatim wording from the response “V. Newborn Early Warning Observation charts – documented by Midwives, consulted by Doctors” Source location 2019-0481-Response-by-Gloucestershire-Hospitals-NHS-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 Hold a Trust Safety Department Black Box learning event to explore barriers to escalation and improve multiprofessional learning from incidents.
Verbatim wording from the response “Finally, I can also add that as a result of the inquest into Elisa’s death, the following additional review and learning has taken place, for the clinical staff involved, and for any interested colleagues:” Source location 2019-0481-Response-by-Gloucestershire-Hospitals-NHS-Trust
Open published response
18 Apr 2019 Graham Philip Jones · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 4 Insufficient handover of patient safety information during transfers between wards View source Insufficient understanding that post-fall medical reviews must include review of current medications View source Insufficient consideration of falls prevention measures on the surgical ward View source Insufficient understanding of the post-falls protocol on the surgical ward 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
Graham Philip Jones · 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
Graham Philip Jones, a 63-year-old man with significant medical conditions, was admitted to hospital with vomiting and abdominal pain and underwent repair of a perforated duodenal ulcer. He suffered several falls in hospital, including a fall that caused a significant head injury; the injury was diagnosed after a delay, and he died on 13 April 2018. The principal concerns related to falls prevention, adherence to the post-falls protocol, review of medication after a fall, and the handover of safety information between wards.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient handover of patient safety information during transfers between wards
Wider context from the report “1. Whether sufficient consideration is given to falls prevention measures on the surgical ward,
2. Whether there is sufficient understanding of the post falls protocol that must be followed on the surgical ward,
3. Whether there is sufficient understanding that a medical review of a patient post fall must include review of their current medications,
4. When a patient is transferred between wards, whether there is sufficient handover of safety information pertaining to a patient .
” 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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding that post-fall medical reviews must include review of current medications
Wider context from the report “1. Whether sufficient consideration is given to falls prevention measures on the surgical ward,
2. Whether there is sufficient understanding of the post falls protocol that must be followed on the surgical ward,
3. Whether there is sufficient understanding that a medical review of a patient post fall must include review of their current medications ,
4. When a patient is transferred between wards, whether there is sufficient handover of safety information pertaining to a patient.
” 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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient consideration of falls prevention measures on the surgical ward
Wider context from the report “1. Whether sufficient consideration is given to falls prevention measures on the surgical ward ,
2. Whether there is sufficient understanding of the post falls protocol that must be followed on the surgical ward,
3. Whether there is sufficient understanding that a medical review of a patient post fall must include review of their current medications,
4. When a patient is transferred between wards, whether there is sufficient handover of safety information pertaining to a patient.
” 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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of the post-falls protocol on the surgical ward
Wider context from the report “1. Whether sufficient consideration is given to falls prevention measures on the surgical ward,
2. Whether there is sufficient understanding of the post falls protocol that must be followed on the surgical ward ,
3. Whether there is sufficient understanding that a medical review of a patient post fall must include review of their current medications,
4. When a patient is transferred between wards, whether there is sufficient handover of safety information pertaining to a patient.
” 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 Provide training and instructions to doctors and nursing staff on assessing and managing prophylactic anticoagulants after falls.
Verbatim wording from the response “After the inquest the Trust has reviewed the medical contribution to post falls management and, in particular, the inpatient post falls assessment sticker. Although this sticker is an effective tool for standardising medical post falls care and assessment, the Trust’s conclusion is that this could be improved. Analysis of Mr Jones’ drug chart shows that he was prescribed a daily dose of anticoagulant in the form of a prophylactic dose of Dalteparin. Despite this, on the post falls assessment stickers the reviewing doctor has answered ‘No’ to the question ‘is the patient on anticoagulation’. The Trust proposes to undertake some work to address the fact that low dose prophylactic anticoagulants in the form that Mr Jones received must be included in this medical assessment, and instructions given to nursing staff as to whether this medication should be continued or stopped.” Source location 2019-0131-Response-by-Gloucestershire-Hospitals-NHS-Trust
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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 Trial modified nurse handover documentation that consolidates safety information and previous handovers across clinical areas on one form.
Verbatim wording from the response “• The Trust nurse handover documentation is currently subject to a Quality Academy Silver project to be presented in June ████████ (Ward 5a) and ████████ (Ward 5b) have trialled a modification to the usual handover process. The modification now enables all previous handovers information from all clinical areas where the patient has been placed to be contained on one form, rather than on several forms from each of the previous clinical settings - the intention is that this will ensure that receiving ward can see a complete history of concerns during that admission of concerns from all the previous clinical settings from which the patient has been transferred, thus giving a more complete picture. This was not available for Mr Jones.” Source location 2019-0131-Response-by-Gloucestershire-Hospitals-NHS-Trust
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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 Train Trust nursing staff in falls assessment, prevention, documentation and post-fall management, with mandatory and educational refreshers.
Verbatim wording from the response “All Trust nursing staff are trained locally in their ward areas on the use of Trust policy and documentation connected with falls assessment, preventative measures and the protocol for managing a patient following a fall. These are regularly refreshed by mandatory training and other educational opportunities.” Source location 2019-0131-Response-by-Gloucestershire-Hospitals-NHS-Trust
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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 Redraft the post-fall assessment sticker to require consideration of low-dose prophylactic anticoagulants.
Verbatim wording from the response “After the inquest the Trust has reviewed the medical contribution to post falls management and, in particular, the inpatient post falls assessment sticker. Although this sticker is an effective tool for standardising medical post falls care and assessment, the Trust’s conclusion is that this could be improved. Analysis of Mr Jones’ drug chart shows that he was prescribed a daily dose of anticoagulant in the form of a prophylactic dose of Dalteparin. Despite this, on the post falls assessment stickers the reviewing doctor has answered ‘No’ to the question ‘is the patient on anticoagulation’. The Trust proposes to undertake some work to address the fact that low dose prophylactic anticoagulants in the form that Mr Jones received must be included in this medical assessment, and instructions given to nursing staff as to whether this medication should be continued or stopped.” Source location 2019-0131-Response-by-Gloucestershire-Hospitals-NHS-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 Undertake the Silver quality-improvement project to improve identification of individual falls risks and consistent use of preventative measures through the Safety Hour Checklist.
Verbatim wording from the response “Evidence was heard from ████████ at the inquest about specific measures being taken to improve staff awareness and appreciation of falls prevention and management on Ward 5b. One main measure is the Silver QI project being undertaken by ████████, part of which is directed at reducing the risk of falls by more reliably acquiring knowledge of individual patient risks, and also ensuring more consistent use of preventative measures eg magnet signage above patients beds (see attached Driver diagram and GSAIA Quality Improvement summary which details the issues to be addressed). The aim of the project is to increase completion of the First Hour Priority Form (renamed Safety Hour Checklist) by 70% by May 2019. This form will record (amongst other factors) the handover of any falls risks for the patient being transferred.” Source location 2019-0131-Response-by-Gloucestershire-Hospitals-NHS-Trust
Open published response
16 Apr 2019 Jonathan Brett Yates · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 1 Failure to communicate patients' nutritional status effectively to hospital staff during admission View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jonathan Brett Yates · 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
Jonathan Brett Yates, aged 68, was admitted to hospital after a fall and had a PEG feeding tube. Although he was nil by mouth, an evening meal was delivered to him; he attempted to eat it, choked, suffered cardiac arrest, and died on 20 March 2018. The substantive concern was how a patient's nil-by-mouth status and nutritional needs are communicated effectively to staff during a hospital admission.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate patients' nutritional status effectively to hospital staff during admission
Wider context from the report “How the nutritional status of a patient, in particular when a patient is nil by mouth, is communicated effectively to staff caring for a patient during an admission to hospital.
” 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 Run safety huddles on selected wards to disseminate patient-safety information and review patients’ nutritional status, including NBM changes.
Verbatim wording from the response “As a practice development, and to increase the quality of handovers, the Trust has recently introduced a pilot of the ‘safety huddle’ concept on selected wards. The aim of this daily event is enable an effective dissemination of patient safety information to the whole ward team, in a structured conversation. This looks in particular at patient needs in terms of falls risks, social work requirements, communication with relatives together with identification of the sickest patients and other immediate priorities such as nutritional status.” Source location 2019-0132-Response-by-Gloucestershire-Hospitals-NHS-Trust
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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 concern concerns a one-off failure to use signage, not a failure to assess or manage the patient’s nutritional needs.
Verbatim wording from the response “However, the concern in this case arises from the failure on one occasion to use signage to safely and effectively communicate Mr Yates’ nutritional status to the clinical team, rather than the assessment and management of his nutritional needs.” Source location 2019-0132-Response-by-Gloucestershire-Hospitals-NHS-Trust
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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 nutritional-management systems are appropriate, available and in use to safely manage patients’ nutritional care.
Verbatim wording from the response “On review of the professional processes by which nutritional status is managed, the Trust is satisfied that appropriate systems are available and in use to safely manage the nutritional care of patients.” Source location 2019-0132-Response-by-Gloucestershire-Hospitals-NHS-Trust
Open published response
25 Oct 2018 Andrea Franzosi · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 1 Failure to provide adequate senior supervision of junior doctors before patient discharge 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
Andrea Franzosi · 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
Andrea Franzosi, a 52-year-old man, presented to hospital with flu-like symptoms and chest pain, was diagnosed with pleurisy and discharged, and died after collapsing the following day. The report identified concern about the supervision of junior doctors, particularly when patients are discharged without examination by a more senior practitioner.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate senior supervision of junior doctors before patient discharge
Wider context from the report “(1) The level of supervision of junior Doctors on the ward . In particular, when a patient is discharged without being examined by a more senior practitioner .
” Open source report
8 May 2018 Jonathan Earp · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 2 Failure to account for and appropriately dispose of unsent fentanyl patches View source Failure to consider concurrent use of additional fentanyl and illicit medication and its effects View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jonathan Earp · 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
Jonathan Earp died at Gloucester Royal Hospital on 10 July 2017 from the effects of prescribed and non-prescribed drugs. Concerns included the management and disposal of Fentanyl patches and the possibility that additional Fentanyl was taken alongside illicit drugs without staff considering the combined effects.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for and appropriately dispose of unsent fentanyl patches
Wider context from the report “I heard during the inquest that Mr Earp had been prescribed Fentanyl which was administered by way of transdermal patches. Mr Earp repeatedly requested additional patches however there was no evidence that all of the "unsent" patches had been returned to the nursing staff or appropriately discarded . The clinical staff believed that Mr Earp was accessing illicit drugs when he left the ward, however there was no evidence that staff considered that he may have been taking additional Fentanyl and illicit medication, and the effect this could have.
” 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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider concurrent use of additional fentanyl and illicit medication and its effects
Wider context from the report “I heard during the inquest that Mr Earp had been prescribed Fentanyl which was administered by way of transdermal patches. Mr Earp repeatedly requested additional patches however there was no evidence that all of the "unsent" patches had been returned to the nursing staff or appropriately discarded. The clinical staff believed that Mr Earp was accessing illicit drugs when he left the ward, however there was no evidence that staff considered that he may have been taking additional Fentanyl and illicit medication, and the effect this could have .
” 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 Document transdermal patch removal and wastage, audit compliance, and provide feedback to ward staff.
Verbatim wording from the response “Improve monitoring of transdermal patch and removal | 1. Document sign removal and wastage of transdermal patches in controlled drug book.” Source location 2018-0135-Response-by-Gloucestershire-Hospitals-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 Check controlled drugs daily and document wastage by two qualified nurses.
Verbatim wording from the response “To check the controlled drugs daily | Check controlled drugs daily and document in controlled drug record book. Also to document all controlled drug wastage by two qualified nurses. | Ward Manager | July 2018 | Current practice” Source location 2018-0135-Response-by-Gloucestershire-Hospitals-NHS-Trust
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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 Establish opioid-user ward management guidelines covering prescribing advice and specialist input.
Verbatim wording from the response “Review policy and flowchart on “OPIOID USERS ON THE WARD – MANAGEMENT GUIDELINES” | These guidelines have been drawn up to advise doctors, nurses and pharmacists on managing patients who have an opioid pain management pathway, and to provide further advice on prescribing from the Acute Pain Management team and/or providers of the Drug dependency service. | Consultant for Acute Pain Management | July 2018 | Complete” Source location 2018-0135-Response-by-Gloucestershire-Hospitals-NHS-Trust
Open published response
22 Nov 2017 Susan Ann Smalley · Prevention of Future Deaths report Gloucestershire
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Concerns raised 3 Insufficient ambulance resources to meet demand in the Gloucestershire area View source Lack of clarity about which hospital should treat the patient View source Failure to appropriately expedite urgent emergency transfers between hospitals 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
Susan Ann Smalley · 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
Susan Ann Smalley, aged 67, suffered a witnessed fall at home on 8 August 2016, sustaining a significant head injury. Delays occurred in the initial ambulance response, the diagnosis and transfer between hospitals, and the urgent transfer for neurosurgical care; she died on 12 August 2016 after active care was withdrawn. The principal concerns related to ambulance resources, clarity about which hospital should treat patients, and how urgent inter-hospital transfers are expedited.
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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient ambulance resources to meet demand in the Gloucestershire area
Wider context from the report “1. The sufficiency of ambulance resources that have been allocated to meet demand in the Gloucestershire area ,
” 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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about which hospital should treat the patient
Wider context from the report “2. Whether clinicians, patients and paramedics are clear as to which hospital, either Gloucester Royal Hospital or Cheltenham General hospital, should be treating the patient .
” 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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately expedite urgent emergency transfers between hospitals
Wider context from the report “3. When urgent emergency transfers are requested between hospitals, how they are appropriately expedited .
” Open source report
6 Apr 2017 Steven John Amos · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 1 Failure to appropriately escalate care for patients who acutely deteriorate during night shifts over weekends 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
Steven John Amos · 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
Steven John Amos died after a leak from a gastrojejunal anastomosis led to peritonitis and multiple organ failure following emergency abdominal surgery. The principal concern was whether care was escalated appropriately when a patient acutely deteriorated during night shifts over the weekend; senior medical review, antibiotics and urgent CT scanning did not occur until 8am, and surgery took place at 2pm.
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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately escalate care for patients who acutely deteriorate during night shifts over weekends
Wider context from the report “Whether there is appropriate escalation of care given to a patient who acutely deteriorates during the night shifts over the weekend period.
” Open source report
21 Oct 2015 Samantha Beach · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 3 Failure to escalate clinical care to more senior colleagues in the obstetric department View source Failure to involve the obstetric department in Emergency Department care for post-natal patients View source Lack of a process for sharing information and joining up care between community and obstetric providers 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
Samantha Beach · 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
Samantha Beach developed severe chest pain and intermittent tachycardia shortly after giving birth to her third child, but her symptoms were not appropriately investigated or escalated. She later suffered cardiac arrests and died after surgery for bleeding from a ruptured splenic artery aneurysm. Concerns included inadequate escalation of care, poor sharing of information between community and hospital services, and failure to involve the obstetric department when she attended the Emergency Department.
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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate clinical care to more senior colleagues in the obstetric department
Wider context from the report “(1) The clinical care provided to Sam in the obstetric department was not escalated appropriately to more senior colleagues ,
” 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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve the obstetric department in Emergency Department care for post-natal patients
Wider context from the report “(3) When Sam attended the Emergency Department as a post-natal patient (7 days post partum) the obstetric department were not involved in her 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 Gloucestershire Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for sharing information and joining up care between community and obstetric providers
Wider context from the report “(2) When Sam was being cared for in the community, there was no process to ensure the sharing of information or joining up of care between the midwives, out of hours, GP and obstetric department .
” 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