30 Sep 2019 Amy Allan · Prevention of Future Deaths report London Inner (North)
View report summary
Concerns raised 6 Lack of sharing of critical patient information between departments before transfer to PICU View source Lack of a clear post-operative extubation plan or instruction View source Delay in commencing ECMO support View source Failure to reliably convey and record vital information during handover to PICU View source Failure to assign a single properly informed clinician to coordinate complex post-operative care View source Lack of a clear post-operative ECMO support plan or instruction View source See 3 more concerns
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. 10
Action
Develop, test and launch a standardised electronic anaesthetic-to-ICU handover document with accompanying training.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 November 2019. View source
Action
Publish and use a spinal surgery pathway guideline defining responsibilities for complex cardiac patients admitted to PICU.
Stated completedThe respondent said that this action was complete when they made their response on 13 November 2019. View source
Action
Disseminate agreed Trust-wide MDT attendance and documentation requirements to operational clinical teams.
Stated plannedThe respondent said that this action was planned when they made their response on 13 November 2019. View source
Action
Use Epic to record MDT outcomes and link clinician messages directly to patient records for cross-department information sharing.
Stated completedThe respondent said that this action was complete when they made their response on 13 November 2019. View source
Action
Develop Trust-wide best-practice guidance for MDT attendance, documentation, information dissemination and completion of resulting actions.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 November 2019. View source
Action
Require high-risk patient flagging, PICU team briefings, admission reminders and daily admission-risk discussions for elective spinal admissions.
Stated completedThe respondent said that this action was complete when they made their response on 13 November 2019. View source
Action
Mandate attendance, cover, documentation and case-discussion requirements for the spinal MDT and other required specialties.
Stated completedThe respondent said that this action was complete when they made their response on 13 November 2019. View source
Action
Implement the spinal surgery ECMO pathway, including Joint Cardiac Conference review, postoperative location and consent planning, capacity checks, Epic documentation and multidisciplinary handovers.
Stated completedThe respondent said that this action was complete when they made their response on 13 November 2019. View source
Action
Reinforce consultant-to-consultant handover requirements and record additional anaesthetic-PICU discussions in Epic.
Stated completedThe respondent said that this action was complete when they made their response on 13 November 2019. View source
Action
Expand Anaesthetic Pre-Operative Assessment triage to elective general-anaesthetic patients and identify high-risk patients for Complex Patient MDT planning.
Stated plannedThe respondent said that this action was planned when they made their response on 13 November 2019. View source See 7 more actions
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AI-generated summary
Amy Allan · 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
Amy Allan underwent elective corrective spinal surgery on 4 September 2018 and subsequently suffered severe deterioration, requiring ECMO support before dying on 28 September 2018. Concerns included inadequate pre-operative planning for ECMO, poor communication and handover between departments, extubation while her condition was deteriorating, delayed ECMO support, and a lack of clear co-ordination of her post-operative care.
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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 Great Ormond Street Hospital for Children NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of sharing of critical patient information between departments before transfer to PICU
Wider context from the report “I am concerned that:
(a) It appears there was a lack of awareness and sharing of information between departments at Great Ormond Street Hospital. In particular, the PICU had not been given any advance warning of Amy’s complex medical background and needs before she was admitted there post operation. As PICU staff were not invited to the Multi-Disciplinary Team meetings prior to the operation, they were not aware of the “critical time” which lay ahead for her ;
(b) There was no clear plan or instruction for the management of Amy post operation in relation to extubation and ECMO support on the PICU;
(c) The handover between clinicians involved in Amy’s operation and those taking over her care in the PICU, was poorly executed with vital information either not properly conveyed or recorded or simply missed;
(d) There was a delay in commencing ECMO support, and
(e) No single properly informed clinician appeared to be co-ordinating Amy’s post-operative care in such a complex and high risk case.
” 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 Great Ormond Street Hospital for Children NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear post-operative extubation plan or instruction
Wider context from the report “I am concerned that:
(a) It appears there was a lack of awareness and sharing of information between departments at Great Ormond Street Hospital. In particular, the PICU had not been given any advance warning of Amy’s complex medical background and needs before she was admitted there post operation. As PICU staff were not invited to the Multi-Disciplinary Team meetings prior to the operation, they were not aware of the “critical time” which lay ahead for her;
(b) There was no clear plan or instruction for the management of Amy post operation in relation to extubation and ECMO support on the PICU;
(c) The handover between clinicians involved in Amy’s operation and those taking over her care in the PICU, was poorly executed with vital information either not properly conveyed or recorded or simply missed;
(d) There was a delay in commencing ECMO support, and
(e) No single properly informed clinician appeared to be co-ordinating Amy’s post-operative care in such a complex and high risk case.
” 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 Great Ormond Street Hospital for Children NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in commencing ECMO support
Wider context from the report “I am concerned that:
(a) It appears there was a lack of awareness and sharing of information between departments at Great Ormond Street Hospital. In particular, the PICU had not been given any advance warning of Amy’s complex medical background and needs before she was admitted there post operation. As PICU staff were not invited to the Multi-Disciplinary Team meetings prior to the operation, they were not aware of the “critical time” which lay ahead for her;
(b) There was no clear plan or instruction for the management of Amy post operation in relation to extubation and ECMO support on the PICU;
(c) The handover between clinicians involved in Amy’s operation and those taking over her care in the PICU, was poorly executed with vital information either not properly conveyed or recorded or simply missed;
(d) There was a delay in commencing ECMO support , and
(e) No single properly informed clinician appeared to be co-ordinating Amy’s post-operative care in such a complex and high risk case.
” 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 Great Ormond Street Hospital for Children NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably convey and record vital information during handover to PICU
Wider context from the report “I am concerned that:
(a) It appears there was a lack of awareness and sharing of information between departments at Great Ormond Street Hospital. In particular, the PICU had not been given any advance warning of Amy’s complex medical background and needs before she was admitted there post operation. As PICU staff were not invited to the Multi-Disciplinary Team meetings prior to the operation, they were not aware of the “critical time” which lay ahead for her;
(b) There was no clear plan or instruction for the management of Amy post operation in relation to extubation and ECMO support on the PICU;
(c) The handover between clinicians involved in Amy’s operation and those taking over her care in the PICU, was poorly executed with vital information either not properly conveyed or recorded or simply missed ;
(d) There was a delay in commencing ECMO support, and
(e) No single properly informed clinician appeared to be co-ordinating Amy’s post-operative care in such a complex and high risk case.
” 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 Great Ormond Street Hospital for Children NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign a single properly informed clinician to coordinate complex post-operative care
Wider context from the report “I am concerned that:
(a) It appears there was a lack of awareness and sharing of information between departments at Great Ormond Street Hospital. In particular, the PICU had not been given any advance warning of Amy’s complex medical background and needs before she was admitted there post operation. As PICU staff were not invited to the Multi-Disciplinary Team meetings prior to the operation, they were not aware of the “critical time” which lay ahead for her;
(b) There was no clear plan or instruction for the management of Amy post operation in relation to extubation and ECMO support on the PICU;
(c) The handover between clinicians involved in Amy’s operation and those taking over her care in the PICU, was poorly executed with vital information either not properly conveyed or recorded or simply missed;
(d) There was a delay in commencing ECMO support, and
(e) No single properly informed clinician appeared to be co-ordinating Amy’s post-operative care in such a complex and high risk case.
” 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 Great Ormond Street Hospital for Children NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear post-operative ECMO support plan or instruction
Wider context from the report “I am concerned that:
(a) It appears there was a lack of awareness and sharing of information between departments at Great Ormond Street Hospital. In particular, the PICU had not been given any advance warning of Amy’s complex medical background and needs before she was admitted there post operation. As PICU staff were not invited to the Multi-Disciplinary Team meetings prior to the operation, they were not aware of the “critical time” which lay ahead for her;
(b) There was no clear plan or instruction for the management of Amy post operation in relation to extubation and ECMO support on the PICU;
(c) The handover between clinicians involved in Amy’s operation and those taking over her care in the PICU, was poorly executed with vital information either not properly conveyed or recorded or simply missed;
(d) There was a delay in commencing ECMO support, and
(e) No single properly informed clinician appeared to be co-ordinating Amy’s post-operative care in such a complex and high risk case.
” 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 Develop, test and launch a standardised electronic anaesthetic-to-ICU handover document with accompanying training.
Verbatim wording from the response “The Electronic Patient Record department is currently supporting the Anaesthetic and ICU teams to develop a standardised electronic handover document which mirrors the paper form which has been developed for this purpose. The electronic handover document will ensure that all the relevant fields are together in one section so that they can be clearly and easily discussed as part of a structured verbal handover, and act as an ongoing plan to support the ICU team.” Source location 2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
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 Publish and use a spinal surgery pathway guideline defining responsibilities for complex cardiac patients admitted to PICU.
Verbatim wording from the response “To ensure that all staff members involved in the care are clear about the pathway, and their roles and responsibilities within that pathway, the PICU Consultant Team have now developed a guideline on the spinal surgery pathway for complex cardiac patients admitted to PICU. A copy of this guideline is enclosed [Spinal Surgery Pathway PICU FINAL].” Source location 2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
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 Disseminate agreed Trust-wide MDT attendance and documentation requirements to operational clinical teams.
Verbatim wording from the response “• Improving the governance of MDT meetings
○ Amy’s journey demonstrated how important it is that the Trust has good governance arrangements in place for all MDT meetings to ensure that all relevant clinicians are in attendance; that meetings are appropriately documented and the information disseminated effectively to the right staff; and that all actions arising from MDTs are completed;
○ A consultant surgeon has been identified by the Medical Director to lead a project to guide best practice in conducting MDTs across the Trust. This began in October 2019;
○ Trust wide requirements for MDT attendance and documentation have now been agreed. The requirements will be shared with the Operational Board on the 11th December 2019 for dissemination to operational clinical teams to action.” Source location 2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
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 Epic to record MDT outcomes and link clinician messages directly to patient records for cross-department information sharing.
Verbatim wording from the response “In April 2019 the Trust launched a new electronic patient record system (Epic) that replaces the previous paper records and combines numerous existing electronic systems. Epic now enables the notes of MDT meetings to be recorded directly within the individual patient’s records. It is therefore much easier for all teams involved in caring for a patient to access the outcome of the MDT discussions. Epic also includes a messaging system (similar to email) within the patient’s records to support clinicians discussing the patient’s care and to ensure that those messages are directly linked to the patient’s records. This provides a much better awareness and sharing of information between departments.” Source location 2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
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 Trust-wide best-practice guidance for MDT attendance, documentation, information dissemination and completion of resulting actions.
Verbatim wording from the response “• Improving the governance of MDT meetings
○ Amy’s journey demonstrated how important it is that the Trust has good governance arrangements in place for all MDT meetings to ensure that all relevant clinicians are in attendance; that meetings are appropriately documented and the information disseminated effectively to the right staff; and that all actions arising from MDTs are completed;
○ A consultant surgeon has been identified by the Medical Director to lead a project to guide best practice in conducting MDTs across the Trust. This began in October 2019;
○ Trust wide requirements for MDT attendance and documentation have now been agreed. The requirements will be shared with the Operational Board on the 11th December 2019 for dissemination to operational clinical teams to action.” Source location 2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
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 Require high-risk patient flagging, PICU team briefings, admission reminders and daily admission-risk discussions for elective spinal admissions.
Verbatim wording from the response “In addition to the safety improvements which Epic brings, the Trust has made a number of changes to ensure that the outcome of the spinal MDT meeting are effectively communicated. This includes:” Source location 2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
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 Mandate attendance, cover, documentation and case-discussion requirements for the spinal MDT and other required specialties.
Verbatim wording from the response “The PICU Consultant is an important member of the spinal MDT meeting as many of the spinal patients are initially cared for in PICU post operatively. When Amy’s case was discussed at the spinal MDT meetings, the PICU consultant was not present. Although routinely invited to the monthly spinal MDT meeting, and were specifically invited to both of the spinal MDTs at which Amy was discussed, the PICU consultant was unable to attend. The Terms of Reference (TOR) for the MDT have now been amended to mandate the need for the attendance of the identified PICU consultant who acts as liaison with the Spinal Team. The TOR also now reflects the responsibility of the PICU consultant to arrange appropriate PICU consultant level cover for the spinal MDT meeting in the event that they are unable to attend.” Source location 2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
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 Implement the spinal surgery ECMO pathway, including Joint Cardiac Conference review, postoperative location and consent planning, capacity checks, Epic documentation and multidisciplinary handovers.
Verbatim wording from the response “The Spinal MDT TOR have been amended to include the specific responsibilities for clinicians attending the meeting in regards to ECMO. This is reiterated in the PICU guidance for managing spinal patients. A copy of this guidance is enclosed [Spinal Surgery Pathway PICU FINAL].” Source location 2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
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 Reinforce consultant-to-consultant handover requirements and record additional anaesthetic-PICU discussions in Epic.
Verbatim wording from the response “The Trust expects this handover to take place between the Anaesthetic Consultant and the PICU Consultant whenever possible. The Clinical Lead for PICU and the Clinical Lead for Anaesthetics have reminded all Consultants of this requirement again in November 2019. When it is not possible (e.g. PICU Consultant is busy with another patient), handover should be given to the most senior doctor on the unit, who will then share that information, alongside the handover document, with the PICU Consultant. Where further discussions about the patient between the Anaesthetic Consultant and the PICU Consultant are required, these are now recorded in Epic. It is the responsibility of the PICU Consultant to record this information.” Source location 2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
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 Expand Anaesthetic Pre-Operative Assessment triage to elective general-anaesthetic patients and identify high-risk patients for Complex Patient MDT planning.
Verbatim wording from the response “In addition to strengthening the pathways for spinal patients with complex co-morbidities, the Trust has also reviewed how it can apply the learning from Amy’s case to other surgical pathways. As a result two significant projects are now underway:” Source location 2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
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 Extubation plans appropriately evolve with the patient’s condition, with the PICU Consultant responsible for decisions and communicating the plan.
Verbatim wording from the response “The plans and instructions for management of extubation are guided by the patient’s consultant anaesthetist on the basis of the patient’s response to the general anaesthetic on the day of the procedure. This means that the handover between the anaesthetic and PICU team is a crucial safety mechanism. The changes which the Trust has made in relation to the anaesthetic-PICU handover are outlined in paragraph (c).” Source location 2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
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 ECMO response involves inherent delays, lacks defined cannulation timescales, and does not include a resident out-of-hours perfusion service because unanticipated rescue ECLS is rare.
Verbatim wording from the response “There are inherent delays in this approach and there are no local, national or international timescales for ECMO cannulation. Whilst the ECMO team always works hard to avoid unnecessary delays, it is recognised that it is not always possible to get this judgement right and they err on the side of safety. Often transferring a critically ill patient to Great Ormond Street for ECMO or assembling the ECMO team does not culminate in cannulation for ECMO because it has been possible to stabilise the patient with conventional ICU therapy. In that situation the ECMO team is retained ‘on standby’ in case of deterioration.” Source location 2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
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 closed intensive care model clearly assigns responsibility for PICU care and identifies the PICU Consultant as the decision maker.
Verbatim wording from the response “The PICU Consultant had responsibility for Amy’s post-operative care following transfer to the unit. The Trust operates a closed intensive care model. A closed intensive care model is when the responsibility for decision making is taken by the intensive care unit consultants. This is done in collaboration with other specialists, including the surgeons and anaesthetists, but the intensivists are the decision makers and they direct care for the patients whilst they remain on ICU. The ICU is staffed with intensivists directly responsible for care.” Source location 2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust does not routinely provide rescue ECLS for every patient who collapses, but aims to provide it where benefit is likely.
Verbatim wording from the response “The Trust does not standardly provide rescue extra corporeal life support (ECLS) for all other patients who may collapse within the Trust. However, the Trust aims to provide ECLS wherever possible to patients who are likely to gain benefit. The decision to deploy ECLS routinely includes:” Source location 2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations