Recipient

Great Western Hospital

First report 8 Apr 2014•Latest report 19 Nov 2025

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 4
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

19 Nov2025
Wiltshire and Swindon
Concerns raised1
1. Failure to notify methadone prescribing authorities of hospital admissions for opioid overdose
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

Anna Maria Burns · 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

Anna Maria Burns was found unresponsive on 12 January 2024 after taking more than her prescribed amounts of medication, including methadone, and was declared deceased that day. The inquest concluded that she died from multidrug toxicity involving methadone, zopiclone and pregabalin, while her intent remained unclear. The principal concern was that the methadone prescribing authority was not informed of her November 2023 opioid overdose and hospital admission, limiting its ability to review overdose risks and prescribing arrangements.

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 Great Western Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to notify methadone prescribing authorities of hospital admissions for opioid overdose
Wider context from the report
“(1) The prescribing agency (for methadone) was unaware of the opiate overdose in November 2023 and the resultant hospital admission until the inquest, and after Anna's death. (2) Whilst a discharge summary was properly sent to the (previous) GP, no such notice regarding the opiate overdose was sent to the opiate prescribing authority. (3) Evidence was heard at the inquest that had the prescribing authority known of the opioid overdose in November 2023, they would have reviewed her case and likely would have put in place restrictive prescribing practices (such as lower or single daily doses, possibly supervised). It is also possible that they may have contacted the GP to warn them of the increased risk. Evidence was heard that not knowing of such an admission left the prescribing authority in a position of potentially approving inappropriate prescribing regimes (with risk of overdose in such cases). (4) I did not find that GWH's were in any way obliged to send the discharge summary to the prescribing agency, and neither was such an omission causative or contributory to Anna's death. I did not find the prescribing regime was inappropriate, but it is possible that in other or future cases, a prescribing agency could be unaware that a patient had been treated for overdose at hospital and would therefore be unable to properly review the overdose risks to its patients in an informed way, and that future deaths may occur as a result. (5) It should be considered that notification to relevant parties (especially methadone prescribing authorities) regarding hospital admission for drug overdoses take place in the same manner as GP's highlighting the nature of the admission (i.e. overdose). ”
Open source report
17 Nov2023
Wiltshire and Swindon
Concerns raised2
1. Failure to complete initial falls risk assessments using all available information
2. Failure to dynamically provide enhanced supervision for changing patient needs
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

Raymond Lionel Eggleton · 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

Raymond Lionel Eggleton died in hospital on 25 January 2023 after falling on a medical unit, sustaining a fractured neck of femur and head injuries, and subsequently developing dysphagia, immobility, delirium and aspiration pneumonia. The principal concerns were that his falls risk assessment did not use all available information about his previous falls and postural hypotension, resulting in inadequate supervision, and that the ward lacked sufficient flexibility and resilience to respond dynamically to vulnerable patients’ enhanced care needs, particularly during night shifts.

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 Great Western Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete initial falls risk assessments using all available information
Wider context from the report
“During the course of the Inquest, I also heard evidence from Sister Jones and in addition to the challenge of getting the staffing levels commensurate to the patients needs and safeguarding patients there does appear to be an issue that causes me a concern as regards the ability to dynamically respond to a need for enhanced supervision especially entering into night shifts. Sister Jones when questioned was open and extremely candid in her answer that at those times nursing staff could not always support those additional needs in the short term because of the challenge to get additional personal at short notice in circumstances where the nursing team were under pressure due to the complexities and demands of patient’s needs. There is in my view no flexibility and resilience within the system to dynamically adapt and respond to changing patients enhanced needs exacerbated by the fact that especially during the winter months those beds are mainly occupied by the elderly. It is easier during day shifts to respond but there clearly appears to be an issue especially going into night shifts. There were 2 issues here, firstly the initial falls risk assessment on LAMU which was not undertaken taking advantage of all available information which in my view led to an incorrect assessment of Ray’s supervision needs. His fall was observed by another member of the nursing staff and therefore my view is that only arm’s length supervision would have avoided the fall and that there were sufficient indicators on two occasions prior to the event occurring. The failure here in relation to the initial assessment was down to the volume of work and not in my view laziness or anything of that nature on the part of nursing staff. Flowing from the first issue a further issue relates to the resilience and the ability to respond dynamically with changing patients on the ward so as to ensure that vulnerable patients with a high degree of risk of falling, like Ray, are properly safeguarded. ”
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 Western Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to dynamically provide enhanced supervision for changing patient needs
Wider context from the report
“During the course of the Inquest, I also heard evidence from Sister Jones and in addition to the challenge of getting the staffing levels commensurate to the patients needs and safeguarding patients there does appear to be an issue that causes me a concern as regards the ability to dynamically respond to a need for enhanced supervision especially entering into night shifts. Sister Jones when questioned was open and extremely candid in her answer that at those times nursing staff could not always support those additional needs in the short term because of the challenge to get additional personal at short notice in circumstances where the nursing team were under pressure due to the complexities and demands of patient’s needs. There is in my view no flexibility and resilience within the system to dynamically adapt and respond to changing patients enhanced needs exacerbated by the fact that especially during the winter months those beds are mainly occupied by the elderly. It is easier during day shifts to respond but there clearly appears to be an issue especially going into night shifts. There were 2 issues here, firstly the initial falls risk assessment on LAMU which was not undertaken taking advantage of all available information which in my view led to an incorrect assessment of Ray’s supervision needs. His fall was observed by another member of the nursing staff and therefore my view is that only arm’s length supervision would have avoided the fall and that there were sufficient indicators on two occasions prior to the event occurring. The failure here in relation to the initial assessment was down to the volume of work and not in my view laziness or anything of that nature on the part of nursing staff. Flowing from the first issue a further issue relates to the resilience and the ability to respond dynamically with changing patients on the ward so as to ensure that vulnerable patients with a high degree of risk of falling, like Ray, are properly safeguarded. ”
Open source report
6 Oct2023
Wiltshire and Swindon
Concerns raised2
1. DVT risk assessment failing to account for immobilisation when determining anti-clotting medication prescribing
2. Risk of deep vein thrombosis from lower-limb immobility associated with wearing a plastic boot
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

Adam Connolly Stuyvesant · 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

Adam Connolly Stuyvesant was involved in a minor road traffic collision on 17 August 2022 and sustained an ankle injury that was immobilised with a plastic boot. He collapsed on 22 August 2022 and died despite resuscitation efforts; the post-mortem confirmed pulmonary embolus arising from deep vein thrombosis associated with lower-limb immobilisation. The report raised concerns that the hospital’s DVT risk assessment did not account for immobilisation when considering anti-clotting medication.

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 Great Western Hospital; that does not assign responsibility.
PFD Monitor interpretation
DVT risk assessment failing to account for immobilisation when determining anti-clotting medication prescribing
Wider context from the report
“(1) The wearing of a plastic boot can lead to lower limb immobility and the possibility of a restriction in the “calf pump function” which can lead to deep vein thrombosis. (2) The DVT risk assessment in use in the Emergency Department at The Great Western Hospital, made no provision to take account of the immobilisation when considering whether anti-clotting medication should be prescribed. (3) That without taking account of the immobility, as part of the DVT risk assessment, further patients may not be prescribed anti-clotting medication and as a result develop DVT, resulting in death from pulmonary embolus. ”
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 Western Hospital; that does not assign responsibility.
PFD Monitor interpretation
Risk of deep vein thrombosis from lower-limb immobility associated with wearing a plastic boot
Wider context from the report
“(1) The wearing of a plastic boot can lead to lower limb immobility and the possibility of a restriction in the “calf pump function” which can lead to deep vein thrombosis. (2) The DVT risk assessment in use in the Emergency Department at The Great Western Hospital, made no provision to take account of the immobilisation when considering whether anti-clotting medication should be prescribed. (3) That without taking account of the immobility, as part of the DVT risk assessment, further patients may not be prescribed anti-clotting medication and as a result develop DVT, resulting in death from pulmonary embolus. ”
Open source report
8 Apr2014
Wiltshire and Swindon
Concerns raised2
1. Failure of the communication pathway for engaging mental health professionals to be clear and effective
2. Lack of staff knowledge of referral procedures for engaging mental health professionals
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

Andrew Michael Horgan · 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

Andrew Michael Horgan died on 16 September 2013 from acute cardiac failure following a Colchicine overdose, with coronary artery atherosclerosis, myocardial fibrosis and focal incomplete hepatic cirrhosis also identified. The principal concern was that hospital staff lacked a clear understanding of referral procedures for mental health assessment following discharge, creating a risk that similar communication failures could contribute to a future death.

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 Great Western Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of the communication pathway for engaging mental health professionals to be clear and effective
Wider context from the report
“1. Training for Doctors and other medical staff in relation to referring patients for assessment both within the hospital and externally following discharge. – During the course of the Inquest ████████ gave evidence and it was quite clear that he did not have a clear understanding of the referral procedure to involve professionals from the Avon and Wiltshire Mental Health Partnership. He believed his telephone conversation with the Swindon Intensive Services with CPN ████████ would result in the outreach team assessing Andrew in the community. He thought that a telephone call alone would be sufficient in that respect to engage the Mental Healthcare professionals. The importance of a clear and effective communication pathway following recognised and agreed practices and procedures cannot be ignored and I am concerned following the evidence I heard there were knowledge gaps as regards practice and procedures to be followed when engaging Mental Health Partnership personnel. I would be grateful if you could please review the appropriateness and the effectiveness of training in this respect not only for current GWH personnel but also how effective training in this area can be given to personnel in the future. Whilst I was satisfied that this did not contribute to Andrew’s death in this instance my concern is that an issue could arise in the future whereby that may not be the 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 Western Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of staff knowledge of referral procedures for engaging mental health professionals
Wider context from the report
“1. Training for Doctors and other medical staff in relation to referring patients for assessment both within the hospital and externally following discharge. – During the course of the Inquest ████████ gave evidence and it was quite clear that he did not have a clear understanding of the referral procedure to involve professionals from the Avon and Wiltshire Mental Health Partnership. He believed his telephone conversation with the Swindon Intensive Services with CPN ████████ would result in the outreach team assessing Andrew in the community. He thought that a telephone call alone would be sufficient in that respect to engage the Mental Healthcare professionals. The importance of a clear and effective communication pathway following recognised and agreed practices and procedures cannot be ignored and I am concerned following the evidence I heard there were knowledge gaps as regards practice and procedures to be followed when engaging Mental Health Partnership personnel. I would be grateful if you could please review the appropriateness and the effectiveness of training in this respect not only for current GWH personnel but also how effective training in this area can be given to personnel in the future. Whilst I was satisfied that this did not contribute to Andrew’s death in this instance my concern is that an issue could arise in the future whereby that may not be the case. ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised1

Failure to notify methadone prescribing authorities of hospital admissions for opioid overdose

Concerns raised2

Failure to complete initial falls risk assessments using all available information

Failure to dynamically provide enhanced supervision for changing patient needs

Concerns raised2

DVT risk assessment failing to account for immobilisation when determining anti-clotting medication prescribing

Risk of deep vein thrombosis from lower-limb immobility associated with wearing a plastic boot

Concerns raised2

Failure of the communication pathway for engaging mental health professionals to be clear and effective

Lack of staff knowledge of referral procedures for engaging mental health professionals