10 Sep 2025 Mabel Olivia Williams · Prevention of Future Deaths report Avon
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Concerns raised 3 Failure to maintain and approve current patient information leaflets for distribution View source Delays in implementing appropriate changes following serious clinical incidents View source Failure to provide complete information about uterine rupture and its consequences in patient guidance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Mabel Olivia Williams · 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
Mabel Olivia Williams was born alive after a trial of vaginal birth after caesarean section and died six days later in a neonatal intensive care unit following severe hypoxic-ischaemic encephalopathy associated with an undiagnosed uterine rupture. The concerns included inadequate information and informed consent about the risks of uterine rupture, failures to recognise or communicate signs of distress in time, and delays in making appropriate changes after serious clinical incidents.
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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 Western Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain and approve current patient information leaflets for distribution
Wider context from the report “Background
The Ockenden Report, which I was directed to in evidence, first published in 2020 a list of immediate and essential actions which included: ‘all Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.’
The externally conducted HSIB report which looked into Mabel’s death identified in February 2024 that the Trust’s guidance for patients on ‘Birth after caesarean’ did not describe what a uterine rupture is. That point was made in the context of Mabel’s parents telling the HSIB investigation that they were not informed about the possible consequences of a uterine scar rupture, or that at their most severe those consequences could include the death of their baby.
I found at the conclusion of Mabel’s inquest that appropriate steps had not been taken to obtain ████████ informed consent to VBAC, and the shortcomings of the Trust’s patient information leaflets were part of what informed that finding.
In advance of the inquest the Trust’s legal representatives found it difficult to provide me with current copies of relevant patient information leaflets . When they were finally disclosed (on day 3 of the inquest) I found it hard to get a clear picture of whether the leaflets were or were not ‘in force’ . I heard evidence at one point from a member of trust staff that revised leaflets (which did contain a full explanation of uterine rupture) had been drafted but not signed off by the Trust for distribution to patients , much to the frustration of the maternity unit.
I was also provided with an Excel spreadsheet after the inquest which contained, among other things, information about the Trust’s compliance with various objectives relating to the Ockenden Review. The information in that spreadsheet included an indication that one of the Trust’s objective was that “Change in practice arising from an SI investigation must be seen within 6 months after the incident occurred”. The spreadsheet suggested that this objective was not being achieved. This would accord with my impression (which I would have reached irrespective of having sight of the spreadsheet) that much of the change that I was being shown following Mabel’s death was coming very late, and as a response to the impending (or active) inquest, not as a result of learning from the tragic events in question.
Specific concern
That the Trust may not be making appropriate changes within a reasonable timeframe following serious clinical incidents.
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in implementing appropriate changes following serious clinical incidents
Wider context from the report “Background
The Ockenden Report, which I was directed to in evidence, first published in 2020 a list of immediate and essential actions which included: ‘all Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.’
The externally conducted HSIB report which looked into Mabel’s death identified in February 2024 that the Trust’s guidance for patients on ‘Birth after caesarean’ did not describe what a uterine rupture is. That point was made in the context of Mabel’s parents telling the HSIB investigation that they were not informed about the possible consequences of a uterine scar rupture, or that at their most severe those consequences could include the death of their baby.
I found at the conclusion of Mabel’s inquest that appropriate steps had not been taken to obtain ████████ informed consent to VBAC, and the shortcomings of the Trust’s patient information leaflets were part of what informed that finding.
In advance of the inquest the Trust’s legal representatives found it difficult to provide me with current copies of relevant patient information leaflets. When they were finally disclosed (on day 3 of the inquest) I found it hard to get a clear picture of whether the leaflets were or were not ‘in force’. I heard evidence at one point from a member of trust staff that revised leaflets (which did contain a full explanation of uterine rupture) had been drafted but not signed off by the Trust for distribution to patients, much to the frustration of the maternity unit.
I was also provided with an Excel spreadsheet after the inquest which contained, among other things, information about the Trust’s compliance with various objectives relating to the Ockenden Review. The information in that spreadsheet included an indication that one of the Trust’s objective was that “Change in practice arising from an SI investigation must be seen within 6 months after the incident occurred”. The spreadsheet suggested that this objective was not being achieved . This would accord with my impression (which I would have reached irrespective of having sight of the spreadsheet) that much of the change that I was being shown following Mabel’s death was coming very late, and as a response to the impending (or active) inquest, not as a result of learning from the tragic events in question .
Specific concern
That the Trust may not be making appropriate changes within a reasonable timeframe following serious clinical incidents.
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide complete information about uterine rupture and its consequences in patient guidance
Wider context from the report “Background
The Ockenden Report, which I was directed to in evidence, first published in 2020 a list of immediate and essential actions which included: ‘all Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.’
The externally conducted HSIB report which looked into Mabel’s death identified in February 2024 that the Trust’s guidance for patients on ‘Birth after caesarean’ did not describe what a uterine rupture is . That point was made in the context of Mabel’s parents telling the HSIB investigation that they were not informed about the possible consequences of a uterine scar rupture, or that at their most severe those consequences could include the death of their baby .
I found at the conclusion of Mabel’s inquest that appropriate steps had not been taken to obtain ████████ informed consent to VBAC, and the shortcomings of the Trust’s patient information leaflets were part of what informed that finding.
In advance of the inquest the Trust’s legal representatives found it difficult to provide me with current copies of relevant patient information leaflets. When they were finally disclosed (on day 3 of the inquest) I found it hard to get a clear picture of whether the leaflets were or were not ‘in force’. I heard evidence at one point from a member of trust staff that revised leaflets (which did contain a full explanation of uterine rupture) had been drafted but not signed off by the Trust for distribution to patients, much to the frustration of the maternity unit.
I was also provided with an Excel spreadsheet after the inquest which contained, among other things, information about the Trust’s compliance with various objectives relating to the Ockenden Review. The information in that spreadsheet included an indication that one of the Trust’s objective was that “Change in practice arising from an SI investigation must be seen within 6 months after the incident occurred”. The spreadsheet suggested that this objective was not being achieved. This would accord with my impression (which I would have reached irrespective of having sight of the spreadsheet) that much of the change that I was being shown following Mabel’s death was coming very late, and as a response to the impending (or active) inquest, not as a result of learning from the tragic events in question.
Specific concern
That the Trust may not be making appropriate changes within a reasonable timeframe following serious clinical incidents.
” 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 Move patient information leaflets to an online hosting system accessible through the hospital website.
Verbatim wording from the response “As part of our ongoing commitment to quality and patient safety, the Trust has undertaken a comprehensive review of its procedures for the approval, distribution, and audit of all patient information leaflets. This initiative ensures that only the most current and formally approved versions are in circulation, and that these materials are easily accessible to both staff and patients. By strengthening these processes, we aim to support informed decision-making and enhance the overall patient experience. The Trust is prioritising moving to an online hosting system which will ensure that the public have access to all of the Trust patient information leaflets via the hospital website.” Source location Response from Great Western Hospitals NHS Foundation 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 Review procedures for approving, distributing and auditing patient information leaflets so current approved versions remain accessible.
Verbatim wording from the response “As part of our ongoing commitment to quality and patient safety, the Trust has undertaken a comprehensive review of its procedures for the approval, distribution, and audit of all patient information leaflets. This initiative ensures that only the most current and formally approved versions are in circulation, and that these materials are easily accessible to both staff and patients. By strengthening these processes, we aim to support informed decision-making and enhance the overall patient experience. The Trust is prioritising moving to an online hosting system which will ensure that the public have access to all of the Trust patient information leaflets via the hospital website.” Source location Response from Great Western Hospitals NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and provide the Birth After Previous Caesarean leaflet with clear uterine-rupture risks during birth-options counselling.
Verbatim wording from the response “The Trust has undertaken a comprehensive review of the “Birth After Previous Caesarean” patient information leaflet. The revised leaflet now provides a clear, accessible explanation of uterine rupture, including its potential severity and the associated risks to both mother and baby which includes the risk of the death of the baby.” Source location Response from Great Western Hospitals NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review governance processes to strengthen oversight and accountability for implementing learning and improvement actions.
Verbatim wording from the response “We fully acknowledge the importance of ensuring that learning from serious incidents is translated into practice both promptly and sustainably. To that end, we are undertaking a review of our governance processes to strengthen oversight and accountability for the implementation of learning and improvement actions.” Source location Response from Great Western Hospitals NHS Foundation 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 Strengthen and embed central tracking and monitoring of serious-incident actions, with prompts, responsibility visibility and progress evidence.
Verbatim wording from the response “To ensure that learning is not only captured but acted upon in a timely and sustained way, we have strengthened our internal systems for tracking and monitoring progress and this revised governance process will be fully embedded by December 2025. Outstanding actions from the Trust’s serious incident investigations are now held within a centralised platform that supports teams with timely prompts and clear visibility of responsibilities. Colleagues across the organisation have been asked to contribute evidence of progress, reflecting our shared commitment to transparency and improvement. Weekly meetings with the Patient Quality,” Source location Response from Great Western Hospitals NHS Foundation 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 Review outstanding serious-incident investigation actions and monitor them through monthly Maternity Governance meetings.
Verbatim wording from the response “In response to the concerns raised, a full review was undertaken of all outstanding actions from the Trust’s serious incident investigations to fully establish the current compliance position and ensure that learning is being translated into meaningful and timely change. To support continued oversight, these actions are reviewed within our monthly Maternity Governance meetings, enabling senior leaders to monitor progress, escalate concerns, and ensure accountability.” Source location Response from Great Western Hospitals NHS Foundation Trust
Open published response
16 Mar 2022 Billy Longshaw · Prevention of Future Deaths report Manchester South
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Concerns raised 4 Flawed and limited review of serious clinical incidents View source Failure to undertake detailed, rigorous and effective investigations of serious clinical incidents View source Insufficient doctors’ familiarity with the practical application of the Mental Capacity Act 2005 View source Inadequate education on the Mental Capacity Act 2005 for medical students View source See 1 more concern
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
Billy Longshaw · 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
Billy Longshaw died at Stepping Hill Hospital on 7 March 2021 from complications of an undiagnosed sigmoid volvulus, following an earlier Emergency Department assessment at Great Western Hospital. He was allowed to leave without basic blood tests, a diagnosis, or serious abdominal pathology being fully excluded. Concerns included the lack of a detailed investigation by the Trust, flaws in its incident review, and the adequacy of education and practical understanding concerning the Mental Capacity Act 2005.
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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 Western Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Flawed and limited review of serious clinical incidents
Wider context from the report “2) The ’48 Hour Report for Significant incidents resulting in Moderate Harm and above’ prepared by an ED Consultant and others is fundamentally and obviously flawed (even when read against the Trust’s own medical records), prefaced as it is by the assumption that ‘the patient self-discharged against medical advice’ . The Trust’s (limited) review of this matter represents a missed opportunity to consider vital issues such as the presentation of patients with significant learning disabilities to the Emergency Department, and the practical application of the Mental Capacity Act 2005 in this clinical setting .
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake detailed, rigorous and effective investigations of serious clinical incidents
Wider context from the report “1) Notwithstanding Mr Longshaw died within 24 hours of being seen in the Emergency Department at Great Western Hospitals, Swindon, in circumstances where he was permitted to leave without basic blood tests being taken, any diagnosis being made, or serious abdominal pathology being fully excluded, it is a matter of concern that the Trust has not undertaken a detailed investigation into the care and treatment provided to him .
Prompt, rigorous and effective investigations into serious clinical incidents are essential to deriving learning and improving patient safety ;
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient doctors’ familiarity with the practical application of the Mental Capacity Act 2005
Wider context from the report “3) Mr Longshaw’s death raises issues as to the adequacy of education provided to medical students as to the Mental Capacity Act 2005, and doctors’ of all levels familiarity with the practical application of this legislation in clinical settings , and accompanying guidance such as that produced by the General Medical Council in this regard .
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate education on the Mental Capacity Act 2005 for medical students
Wider context from the report “3) Mr Longshaw’s death raises issues as to the adequacy of education provided to medical students as to the Mental Capacity Act 2005 , and doctors’ of all levels familiarity with the practical application of this legislation in clinical settings, and accompanying guidance such as that produced by the General Medical Council in this regard.
” Open source report
25 Jun 2020 Winifred Mary Redfearn · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 1 Delays in resuming Dalteparin after production of a CT report 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
Winifred Mary Redfearn · 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
Winifred Mary Redfearn died after falling down the stairs at home, sustaining head and neck injuries and becoming immobile in hospital. She developed a deep vein thrombosis and pulmonary thromboembolism. The principal concern was that resumption of Dalteparin thromboprophylaxis was delayed for more than two and a half days after the CT report, apparently because of the intervening weekend, and that similar delays could contribute to avoidable premature deaths in other cases.
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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 Western Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in resuming Dalteparin after production of a CT report
Wider context from the report “I had no evidence before me to say more likely than not that it would have made a difference and having dealt with many cases similar to this, I fully recognise that even with venous thromboembolism prophylaxis, the risk of developing a deep vein thrombosis and subsequent pulmonary thromboembolism can never be completely excluded. That having been said I am, however, somewhat concerned that the resumption of Dalteparin took in excess of 2½ days from the production of the CT report and the delay would appear to be solely attributable to the weekend separating the point of which the Dalteparin was stopped and when it was resumed on Monday afternoon . Whilst I accept it may not have made a difference in this particular case, I am concerned that in other cases that such a delay could result in unnecessary premature death of a patient which is why I am raising this concern.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make a new electronic system available for weekend patient reviews, identifying required treatment, allocated clinicians and specialities, with accessible retained information.
Verbatim wording from the response “IT based system for weekend review of patients” Source location 2020-0132-Response-from-Great-Western-Hospitals-NHS-Foundation-Trust_Redacted.pdf
Open published response
16 Oct 2017 Jeremy Michael Holt · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 5 Lack of guidance on the frequency of recording observations for patients scoring 7 or above on NEWS View source Failure to empower nursing staff to refer critically ill patients to the Critical Care Outreach Team View source Delays and unclear responsibility for timely clinician escalation from care plans View source Failure to specify and record timely review points for critically ill patients View source Lack of an available and understood fallback escalation pathway when Critical Care Outreach cannot assess a patient View source See 2 more concerns
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Each statement is shown once, even when linked to more than one concern.
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Jeremy Michael Holt · 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
Jeremy Michael Holt Marshall developed a small bowel obstruction and other complications after elective surgery for colonic adenocarcinoma, deteriorated in hospital, and died on 17 November 2016 after life support was withdrawn. Concerns included delays in escalating his deteriorating condition, insufficiently specified review and fallback arrangements, and inadequate recording of observations for a critically ill patient with a high NEWS score.
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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 Western Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on the frequency of recording observations for patients scoring 7 or above on NEWS
Wider context from the report “3. Recording observations in a patient scoring 7 or above – I was comfortable hearing that a monitor was connected to Dr Marshall when his NEWS score reached 7 which would record observations electronically every 15 minutes and I heard evidence that at some point in 2018 you will be moving to an electronic system. In the interim I am concerned that there is no guidance given as regards the frequency of recording the observations on an Observations Chart in respect of a patient scoring 7 above on the NEWS score. Between 2350 on 14 November 2016 and 0240 on 15 November 2016 nothing was actually recorded on the Observations Chart itself which causes me concern in the interim.
I did indicate to ████████ during the course of the proceedings that I would like to come and visit once this system is in place and have a look for myself at the new software that you have in relation to NEWS scores and other new software that you have introduced in the last 18 months or so. I fully accept that there needs to be a balance as regards overburdening the nursing staff but at the same time I believe conversely that a gap of nearly 3 hours in respect of recorded observations of a critically ill patient is simply too long a gap. Should the frequency of observations be something that should automatically form part of a care plan in respect of a critically ill 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 Great Western Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to empower nursing staff to refer critically ill patients to the Critical Care Outreach Team
Wider context from the report “2. Review Point and fall back position when no further action is forthcoming – ████████ and also ████████ care plan at midnight provided for action to be undertaken but neither care plan provided for a specific timescale for any further review in respect of a patient who was quite clearly critically ill. Both ████████ indicated that with the benefit of hindsight that such a timescale would have been desirable. I am concerned that if there is not a review or further action undertaken and noted within a period of time which at the end of the day has to be reasonable but given the critical nature of patient scoring 7 and above should be relatively short, that if nothing happens that the nursing staff are empowered to refer the matter now to the Critical Care Outreach Team. My concern goes further than that. If hypothetically the Critical Care Outreach Team at a time of significant demand were unable to assess a patient then there needs to be built into that system a fallback position similar to the same fallback position that is available to the doctors ie that the nursing team can contact ITU or even as a last resort on the call Consultant. I am satisfied and I have no doubt in my similar situation that ████████ would have no hesitation in making such a call but I am concerned as to whether or not other members of the nursing team would be aware of those options and that is of concern to me as well as the reinforcement of a review point for a critically ill patient to be actually recorded in the care plan.
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and unclear responsibility for timely clinician escalation from care plans
Wider context from the report “1. Expectations of F1/F2 doctors – personally I have no experience of training or being involved in the training of F1/F2 doctors and my only experience in respect of which I do not see a fundamental dissimilarity is in relation to trainee lawyers or in particular training solicitors in respect of whom I have been involved in their training during my professional career. F1/F2’s when appointed are given a provisional licence to practice at the end of their medical degree. Trainee solicitors are again allowed to work under supervision following the completion of their professional examinations which for example can be a degree combined with a post graduate legal practice course. My experience in relation to trainee solicitors is that the expectations of what they realistically can do is at a low level and having heard from ████████ from whom I was told that it is not fundamentally different in respect of F1/F2 doctors. The Great Western Hospital of course is a teaching hospital and therefore in relation to the training of doctors it is often, I imagine, imperative that what may seem obvious to you or I perhaps needs to be spelled out to those trainees who may be entering the working environment in their chosen career area for the very first time. In relation to Dr Marshall's case I was concerned that the evidence revealed that ████████ had not contacted ████████ until the bleeped him at 0513 despite the care plan in relation to a seriously ill patient who at the time was peripherally shutting down in respect of which both ████████ and ████████ had recognised the seriousness of the condition as to why ████████ was not contacted sooner. There had been a 3 point increase in his NEWS score yet there appeared to be a delay in contacting ████████ to a degree and significant delay in contacting ████████. No instruction had been given to nursing staff to bleep the relevant doctors and I am concerned as to whether or not in respect of all doctors that the point needs to be emphasised that whoever records the care plan on the notes at doctor level should have the responsibility of bleeping another clinician in a timely fashion unless the notes clearly indicate that that responsibility has been given to somebody else and then the notes to identify when and to whom that instruction was given.
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to specify and record timely review points for critically ill patients
Wider context from the report “2. Review Point and fall back position when no further action is forthcoming – ████████ and also ████████ care plan at midnight provided for action to be undertaken but neither care plan provided for a specific timescale for any further review in respect of a patient who was quite clearly critically ill. Both ████████ indicated that with the benefit of hindsight that such a timescale would have been desirable. I am concerned that if there is not a review or further action undertaken and noted within a period of time which at the end of the day has to be reasonable but given the critical nature of patient scoring 7 and above should be relatively short , that if nothing happens that the nursing staff are empowered to refer the matter now to the Critical Care Outreach Team. My concern goes further than that. If hypothetically the Critical Care Outreach Team at a time of significant demand were unable to assess a patient then there needs to be built into that system a fallback position similar to the same fallback position that is available to the doctors ie that the nursing team can contact ITU or even as a last resort on the call Consultant. I am satisfied and I have no doubt in my similar situation that ████████ would have no hesitation in making such a call but I am concerned as to whether or not other members of the nursing team would be aware of those options and that is of concern to me as well as the reinforcement of a review point for a critically ill patient to be actually recorded in the care plan .
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an available and understood fallback escalation pathway when Critical Care Outreach cannot assess a patient
Wider context from the report “2. Review Point and fall back position when no further action is forthcoming – ████████ and also ████████ care plan at midnight provided for action to be undertaken but neither care plan provided for a specific timescale for any further review in respect of a patient who was quite clearly critically ill. Both ████████ indicated that with the benefit of hindsight that such a timescale would have been desirable. I am concerned that if there is not a review or further action undertaken and noted within a period of time which at the end of the day has to be reasonable but given the critical nature of patient scoring 7 and above should be relatively short, that if nothing happens that the nursing staff are empowered to refer the matter now to the Critical Care Outreach Team. My concern goes further than that. If hypothetically the Critical Care Outreach Team at a time of significant demand were unable to assess a patient then there needs to be built into that system a fallback position similar to the same fallback position that is available to the doctors ie that the nursing team can contact ITU or even as a last resort on the call Consultant. I am satisfied and I have no doubt in my similar situation that ████████ would have no hesitation in making such a call but I am concerned as to whether or not other members of the nursing team would be aware of those options and that is of concern to me as well as the reinforcement of a review point for a critically ill patient to be actually recorded in the care plan.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update mandatory Adult Basic Life Support training with emergency and non-emergency delegation scenarios and documentation requirements.
Verbatim wording from the response “The Adult Basic Life Support is annual mandatory face to face training for clinical staff. There is a plan to review the training provided and to update this to include scenario training on what to do in an emergency situation specifically in relation to the delegation of tasks. There is a plan to also include a section on what to do in a non-emergency situation and the importance of documenting delegation details.” Source location 2017-0296-Response-by-The-Great-Western-Hospital-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 Carry out Trust-wide quality-improvement work to improve NEWS recording accuracy and associated actions.
Verbatim wording from the response “Recording observations in a patient’s NEWS is scoring 7 or more
In your letter you felt there was no guidance regarding the frequency of documenting observations. The Trust has a ‘Recognition of the Deteriorating Patient’ policy and this mandates the requirements for measuring and recording of observations. The policy states that for a patient with a NEWS score of 7 or more, observations should be measured continuously and each set of observations recorded. As you heard at Dr Marshall’s inquest, the Trust will be implementing electronic observations in the early part of 2018. In the meantime there is a quality improvement piece of work across the Trust to improve the recording and actions of NEWS. Audit data shows that the NEWS accuracy is consistently over 90%.” Source location 2017-0296-Response-by-The-Great-Western-Hospital-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 Operate a 24-hour continuity plan that routes critical-care support to ITU nursing or ICU medical staff when outreach is unavailable.
Verbatim wording from the response “The Trust has a continuity plan in place so that if the critical care outreach team are not available the bleep is passed to the nurse in charge of ITU or the ICU doctor. This ensures that there is always staff available to provide support when required. The system has been operational 24 hours a day since January 2017 and therefore has been in place during period of winter pressure and has proved to be an effective and beneficial resource in improving patient safety. This is demonstrated by review of ITU admissions and the latest report shows that for the unplanned admissions there is an improving trend in the medical plans being documented and appropriate escalation being undertaken. In addition the number of medical emergency team calls has reduced.” Source location 2017-0296-Response-by-The-Great-Western-Hospital-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 Update the junior surgical doctors’ handbook to cover delegation responsibilities and documented follow-up plans.
Verbatim wording from the response “The Trust has considered your view and is of the belief there is no single solution to this. The omissions most likely stemmed from human factors rather than a system failing. Therefore a multidisciplinary approach is being taken strengthening personal accountability including updates to a handbook, simulation training and Adult Basic Life Support training.” Source location 2017-0296-Response-by-The-Great-Western-Hospital-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 Update simulation training to emphasise clear communication and delegation of responsibility.
Verbatim wording from the response “The Trust also has plans to update simulation training and the Adult Basic Life Support training. Simulation training consists of interactive training sessions relating to real life clinical situations. The Trust plans to incorporate the importance of clarity of communication (including delegating responsibility for tasks) into these sessions. Simulation training sessions which have already been held, have been found to be highly effective in developing the skills of staff.” Source location 2017-0296-Response-by-The-Great-Western-Hospital-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 Install electronic observations with automated, sequential escalation alerts to doctors and implement the system Trust-wide.
Verbatim wording from the response “In the New Year the Trust will be installing an electronic observations IT system. For this the Trust is developing clear algorithms to enable automatic escalation to the doctors, this will be on a loop so if for example the F2 doctors do not respond, this will be escalated to the registrars and will continue through the doctor ranks up to Consultant until someone responds to the escalation alert. I have enclosed the high level roll out plan, you will see we aim to have electronic observations implemented Trust wide by May 2018.” Source location 2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust’s policy already provides guidance requiring continuous observations and recording for patients with NEWS scores of seven or more.
Verbatim wording from the response “Recording observations in a patient’s NEWS is scoring 7 or more
In your letter you felt there was no guidance regarding the frequency of documenting observations. The Trust has a ‘Recognition of the Deteriorating Patient’ policy and this mandates the requirements for measuring and recording of observations. The policy states that for a patient with a NEWS score of 7 or more, observations should be measured continuously and each set of observations recorded. As you heard at Dr Marshall’s inquest, the Trust will be implementing electronic observations in the early part of 2018. In the meantime there is a quality improvement piece of work across the Trust to improve the recording and actions of NEWS. Audit data shows that the NEWS accuracy is consistently over 90%.” Source location 2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing continuity and escalation arrangements ensure staff are always available to support escalation when critical care outreach is unavailable.
Verbatim wording from the response “The Trust has a continuity plan in place so that if the critical care outreach team are not available the bleep is passed to the nurse in charge of ITU or the ICU doctor. This ensures that there is always staff available to provide support when required. The system has been operational 24 hours a day since January 2017 and therefore has been in place during period of winter pressure and has proved to be an effective and beneficial resource in improving patient safety. This is demonstrated by review of ITU admissions and the latest report shows that for the unplanned admissions there is an improving trend in the medical plans being documented and appropriate escalation being undertaken. In addition the number of medical emergency team calls has reduced.” Source location 2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
Open published response
4 Sep 2017 Francis Mortimer LANGLEY · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 3 Failure to engage bedrails for patients with immobility, paralysis and involuntary movements despite bed-fall risk View source Failure to assess bed-fall risk independently of a prior fall from bed View source Failure of bed-fall risk assessments to provide consistent and coherent answers 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
Francis Mortimer LANGLEY · 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
Francis Mortimer LANGLEY fell from a step ladder in November 2016, sustained thoracic spinal fractures and a thoracic cord injury, and became paralysed from the waist down. He later developed hospital-acquired pneumonia and died on 30 April 2017; the principal concern was the assessment and non-use of bedrails despite identified risks and apparently contradictory assessment responses before a subsequent fall from bed.
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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 Western Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to engage bedrails for patients with immobility, paralysis and involuntary movements despite bed-fall risk
Wider context from the report “As part of the evidence when there is a fall in hospital (and I understand that SWICC is now part of Great Western Hospital hence I am writing to you). I always look at the risk assessments. For ease of reference I have enclosed with this letter marked A, a copy of the earliest assessment that I can on file dated 14 December 2016 in Great Western Hospital format which as you will see in response to the question as to whether or not the patient was admitted due to the fall or has fallen since admission and is at the risk of falling again the response is "Yes", although the ultimate decision was not to engage bed safety rails . As already stated Francis was transferred to SWICC on 30 January 2017 and I have been supplied with a screen dump image marked B showing the two assessments carried out on 30 January and 12 February 2017. The style is very different to the Great Western Hospital approach and in conjunction with this I have regard to a statement from ████████ who was Forest Ward Manager at the relevant time marked C. You will see at the bottom of his statement that the reason safety bedrails were not engaged is the fact that Francis did not have a history of falls from bed. I have to say that I am somewhat concerned and found the questions raised by the SWICC assessment and responses to be contradictory. By way of example I will refer you to the assessment that was carried out on 12 February a few days before the fall from bed on 17 February 2017. In response to the question as to whether or not Francis was at risk from falls from bed the answer was “Yes and No”. In relation to whether or not the patient could injure themselves against the rails due to spasms or uncontrolled movements, the answer was “Yes” yet in response to Does the patient have any behaviour that may interfere with the correct use of the safety rails the answer was “No”. The latter two responses to me contradict each other. Francis was noted that he would have been compliant with the use of safety rails. I have dealt with many cases whereby patients have fallen from their bed or chairs or simply collapsed whilst on the ward resulting in that patient sustaining a head injury from which they have died. To me given Francis’ immobility and the fact that he was in a condition with lower limb paralysis that was essentially alien to him and which involved involuntary movements I am concerned that when assessing the risk as to why safety rails were not engaged in the absence of any mental disorder. I know this is a concern shared by his widow. To me the risk of knocking a lower limb against one of the rails is outweighed by protecting a patient against the risk from falling from a bed and sustaining in particular a serious head injury. In reading the SWICC approach it is almost as if the fact that Francis had not had a fall from bed already predetermines that he is not at risk which to me seems an odd way of risk assessment.
I would be grateful if you could please look at the inconsistency that appears to exist between the approach to the use of bedrails on Forest Ward as compared to the rest of Great Western Hospital as I have said the SWICC assessment concerns me in that it is overly complicated and as I have demonstrated has given rise to conflicting answers as part of the assessment process. I would also be grateful for the Trust's consideration in relation to the policy deployed generally when patients suffer whole or partial paralysis as to whether or not automatically those patients should be subject to bedrails. I appreciate it is not entirely black and white but I do find it surprising and I am concerned that bedrails were not engaged as at the 17 February 2017 although as already stated and I wish to emphasise I did not find that the fall contributed to his death.
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess bed-fall risk independently of a prior fall from bed
Wider context from the report “As part of the evidence when there is a fall in hospital (and I understand that SWICC is now part of Great Western Hospital hence I am writing to you). I always look at the risk assessments. For ease of reference I have enclosed with this letter marked A, a copy of the earliest assessment that I can on file dated 14 December 2016 in Great Western Hospital format which as you will see in response to the question as to whether or not the patient was admitted due to the fall or has fallen since admission and is at the risk of falling again the response is "Yes", although the ultimate decision was not to engage bed safety rails. As already stated Francis was transferred to SWICC on 30 January 2017 and I have been supplied with a screen dump image marked B showing the two assessments carried out on 30 January and 12 February 2017. The style is very different to the Great Western Hospital approach and in conjunction with this I have regard to a statement from ████████ who was Forest Ward Manager at the relevant time marked C. You will see at the bottom of his statement that the reason safety bedrails were not engaged is the fact that Francis did not have a history of falls from bed . I have to say that I am somewhat concerned and found the questions raised by the SWICC assessment and responses to be contradictory. By way of example I will refer you to the assessment that was carried out on 12 February a few days before the fall from bed on 17 February 2017. In response to the question as to whether or not Francis was at risk from falls from bed the answer was “Yes and No”. In relation to whether or not the patient could injure themselves against the rails due to spasms or uncontrolled movements, the answer was “Yes” yet in response to Does the patient have any behaviour that may interfere with the correct use of the safety rails the answer was “No”. The latter two responses to me contradict each other. Francis was noted that he would have been compliant with the use of safety rails. I have dealt with many cases whereby patients have fallen from their bed or chairs or simply collapsed whilst on the ward resulting in that patient sustaining a head injury from which they have died. To me given Francis’ immobility and the fact that he was in a condition with lower limb paralysis that was essentially alien to him and which involved involuntary movements I am concerned that when assessing the risk as to why safety rails were not engaged in the absence of any mental disorder. I know this is a concern shared by his widow. To me the risk of knocking a lower limb against one of the rails is outweighed by protecting a patient against the risk from falling from a bed and sustaining in particular a serious head injury. In reading the SWICC approach it is almost as if the fact that Francis had not had a fall from bed already predetermines that he is not at risk which to me seems an odd way of risk assessment.
I would be grateful if you could please look at the inconsistency that appears to exist between the approach to the use of bedrails on Forest Ward as compared to the rest of Great Western Hospital as I have said the SWICC assessment concerns me in that it is overly complicated and as I have demonstrated has given rise to conflicting answers as part of the assessment process. I would also be grateful for the Trust's consideration in relation to the policy deployed generally when patients suffer whole or partial paralysis as to whether or not automatically those patients should be subject to bedrails. I appreciate it is not entirely black and white but I do find it surprising and I am concerned that bedrails were not engaged as at the 17 February 2017 although as already stated and I wish to emphasise I did not find that the fall contributed to his death.
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of bed-fall risk assessments to provide consistent and coherent answers
Wider context from the report “As part of the evidence when there is a fall in hospital (and I understand that SWICC is now part of Great Western Hospital hence I am writing to you). I always look at the risk assessments. For ease of reference I have enclosed with this letter marked A, a copy of the earliest assessment that I can on file dated 14 December 2016 in Great Western Hospital format which as you will see in response to the question as to whether or not the patient was admitted due to the fall or has fallen since admission and is at the risk of falling again the response is "Yes", although the ultimate decision was not to engage bed safety rails. As already stated Francis was transferred to SWICC on 30 January 2017 and I have been supplied with a screen dump image marked B showing the two assessments carried out on 30 January and 12 February 2017. The style is very different to the Great Western Hospital approach and in conjunction with this I have regard to a statement from ████████ who was Forest Ward Manager at the relevant time marked C. You will see at the bottom of his statement that the reason safety bedrails were not engaged is the fact that Francis did not have a history of falls from bed. I have to say that I am somewhat concerned and found the questions raised by the SWICC assessment and responses to be contradictory . By way of example I will refer you to the assessment that was carried out on 12 February a few days before the fall from bed on 17 February 2017. In response to the question as to whether or not Francis was at risk from falls from bed the answer was “Yes and No” . In relation to whether or not the patient could injure themselves against the rails due to spasms or uncontrolled movements, the answer was “Yes” yet in response to Does the patient have any behaviour that may interfere with the correct use of the safety rails the answer was “No”. The latter two responses to me contradict each other . Francis was noted that he would have been compliant with the use of safety rails. I have dealt with many cases whereby patients have fallen from their bed or chairs or simply collapsed whilst on the ward resulting in that patient sustaining a head injury from which they have died. To me given Francis’ immobility and the fact that he was in a condition with lower limb paralysis that was essentially alien to him and which involved involuntary movements I am concerned that when assessing the risk as to why safety rails were not engaged in the absence of any mental disorder. I know this is a concern shared by his widow. To me the risk of knocking a lower limb against one of the rails is outweighed by protecting a patient against the risk from falling from a bed and sustaining in particular a serious head injury. In reading the SWICC approach it is almost as if the fact that Francis had not had a fall from bed already predetermines that he is not at risk which to me seems an odd way of risk assessment.
I would be grateful if you could please look at the inconsistency that appears to exist between the approach to the use of bedrails on Forest Ward as compared to the rest of Great Western Hospital as I have said the SWICC assessment concerns me in that it is overly complicated and as I have demonstrated has given rise to conflicting answers as part of the assessment process . I would also be grateful for the Trust's consideration in relation to the policy deployed generally when patients suffer whole or partial paralysis as to whether or not automatically those patients should be subject to bedrails. I appreciate it is not entirely black and white but I do find it surprising and I am concerned that bedrails were not engaged as at the 17 February 2017 although as already stated and I wish to emphasise I did not find that the fall contributed to his death.
” 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 Implement personalised nursing care plan documentation, including bed-rail and falls assessments, across all inpatient areas.
Verbatim wording from the response “When Great Western Hospitals took over the management of Swindon Community Healthcare Services, each organisation had their own documentation. As with any partnership it takes time to streamline the documentation. I am pleased to update you that from 1 July 2017 the nursing personalised care plan documentation which is used at GWH has been implemented on Forest and Orchard wards (SWICC). The nursing documentation booklet includes bed rails assessment, falls assessment and a care plan. I am sure you are familiar with this document, but I have included a copy of the four day personalised care plan for your perusal. Seven and 14 day versions are available depending on the time the patient is planned to be an inpatient. The assessments and care plans remain the same but there are more pages of the care plan evaluation for the longer admissions.” Source location 2017-00240-Response-by-Great-Western-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Automatic bed rails will not be adopted because each patient requires an individual assessment, including paralysis or partial paralysis.
Verbatim wording from the response “Consider whether patients who suffer from partial or whole paralysis should automatically have bed rails” Source location 2017-00240-Response-by-Great-Western-Hospital-NHS-Trust
Open published response
6 Jun 2017 Joyce Violet Rumming · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 1 Failure of software systems to communicate allergy markers to prescribing clinicians 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
Joyce Violet Rumming · 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
Joyce Violet Rumming attended the Accident and Emergency Department on 11 December 2016 and was given Amoxicillin and Clarithromycin at 01.45 on 12 December 2016; she died just over half an hour later. The stated cause of death was respiratory failure, and the report says this did not appear to be related to an allergic reaction to Amoxicillin. The principal concern was that information about her recorded Amoxicillin allergy was not effectively communicated between systems and staff, resulting in the antibiotic being administered shortly before her death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Great Western Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of software systems to communicate allergy markers to prescribing clinicians
Wider context from the report “The Route Cause Analysis in relation to items (bullet points) under contributory factors documents a number of areas that give rise for concern. It essentially amounts to right hand not communicating with the left hand in that for example unless a Doctor looks in a specific location due to issues as regards the communication between various software packages that the existence of an allergic marker could be missed as was the situation in relation to Joyce's 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 Introduce a new electronic clinical note that includes patient allergies.
Verbatim wording from the response “Action Two – Review of documentation of allergies
The majority of documentation in the Emergency Department is electronic. On the electronic patient record system there is an alert section where drug allergies are to be noted. The alert notification tab is then flagged red on the patient’s home page.” Source location 2017-0182-Response-by-Great-Western-Hospital-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 Migrate the Emergency Department onto the Trust-wide server to improve access to electronic medication records.
Verbatim wording from the response “In addition to this, the Emergency Department are being migrated onto the same server which the rest of the Trust uses. This will make it easier for Emergency Department staff to have access to the electronic patient medication record to look up any allergies and with the potential to prescribe medication using this system.” Source location 2017-0182-Response-by-Great-Western-Hospital-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 Explore the IT infrastructure interface between the electronic medication and patient record systems.
Verbatim wording from the response “Action Three – Explore the interface between IT systems
The IT infrastructure did not and still does not support sharing of information between the electronic patient medication system and the electronic patient record system. Actions two and four are to bridge this gap and ensure patient safety.” Source location 2017-0182-Response-by-Great-Western-Hospital-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 electronic handover system cannot be tailored to place key information, such as allergies, at the top for individual organisations.
Verbatim wording from the response “The Clinical Risk team had liaised with the local ambulance trust to see whether any changes can be made to the electronic system so that key information, such as allergies, is at the top of the handover document. Our local ambulance trust works with many acute hospitals in the South West region. We have been advised that it is not possible to make” Source location 2017-0182-Response-by-Great-Western-Hospital-NHS-Trust
Open published response
26 May 2017 Doreen Helen MILLER · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 9 Failure of the serious-incident review and learning system View source Failure to record the rationale for crucial decisions View source Failure to properly investigate safeguarding referrals before sign-off View source Failure to undertake a mental capacity assessment for a serious and complex decision View source Failure to transfer important cognitive assessment information at discharge View source Insufficient training for therapy-led teams handling complex cases View source Failure of the healthcare-record archiving system to retain and provide records View source Lack of knowledge of Mental Capacity Act safeguarding measure limitations in privately funded community care View source Lack of individual ownership and leadership for MDT decisions View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Doreen Helen MILLER · 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
Doreen Helen MILLER, a vulnerable and housebound adult, was discharged home after an intermediate-care placement despite concerns about unusual toileting behaviour, possible cognitive impairment, self-neglect and limited provisions. She was found severely hypothermic in her cold, dark flat the next morning and died at hospital on 13 January 2016. The principal concerns included safeguarding referrals not being properly investigated, important cognitive information not being communicated, poor record-keeping and decision-making, insufficient assessment of mental capacity, and inadequate systems for reviewing serious incidents and learning from them.
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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 Western Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the serious-incident review and learning system
Wider context from the report “e) (Wiltshire Health & Care) Having commenced a Coronial Investigation I tasked Coroners Officers to make a number of enquiries on my behalf and that included securing statements. As part of documentation that was disclosed by Wiltshire Health and Care was an email from Intermediate Care Lead Carol Langley-Johnson, her email sent to Acting Coroner’s Officer ███████ on 4th July 2016 contained a final paragraph that said “I have no concern about the standards of care provided by my team, I have read their statements and feel that this is a fair representation of rehab she received”. As will have been abundantly clear from reading this report and my Narrative Conclusion I did not share the same view as Ms Langley-Johnson and I am concerned and surprised that prior to the Inquest Final Hearing that no attempt was undertaken to carry out any form of Serious Case Review by Wiltshire Health and Care, formerly Great Western Hospital. I am concerned as regards the system in place that will pick up serious incidents for review and the mechanism in place to undertake investigations with a view to learning points being highlighted, the consideration of procedural changes and the implementation of any changes including additional training needs where required . I am concerned that there may be other incidences where there are learning points where there has not been a review and whilst those incidents may not have resulted in the death of an individual that the learning points have not been recognised and therefore there is the potential out there for repetition and in extreme circumstances repetition of dangerous practice that may lead to death and the involvement of me and my office.
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the rationale for crucial decisions
Wider context from the report “c) (Wiltshire Council, Wiltshire Health & Care and Great Western Hospital) As a general comment, my view in relation to the quality and substance of case notes was that they were poor in quality. My investigation was hampered due to the fact that the Archiving System at Great Western Hospital for Doreen’s therapy led healthcare notes failed in that the notes or at least the scanned images were lost and were not available. Given that some notes were recorded on the Wiltshire Council Care First System and the evidence was that the Healthcare records would not have been significantly different my concerns remain. Crucial and important decisions did not contain any rationale as to why and the basis upon which that decision was being made . As indicated when I summed up the evidence my view is that recording a rationale can act as a check in relation to the decision making process itself as it forces the author to consider the process and information that has led to that decision being made.
I also have concerns in relation to the way MDT’s work and reach decisions. The decisions very much appear in relation to the case decision amongst relevant members of the team as opposed to an individual making the decision based on information provided by relevant team members. There was no leadership. My concern as regards this consensual approach is that no-one actually takes ownership and responsibility for the decision itself and a consensual approach as evidenced in Doreen’s case can in my view lead to a situation whereby there is a false sense of reassurance in believing that nothing more could be done for Doreen that in this case led to wrong decisions being taken.
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly investigate safeguarding referrals before sign-off
Wider context from the report “a) (Wiltshire Council) When Doreen was admitted to hospital on 20th December 2015 the paramedics made a safeguarding referral to Wiltshire Council. Due to the fact that the admission took place on a Sunday the referral fax was sent to the Emergency Out of Hours Team. I was satisfied having heard a copy of the recording that South Western Ambulance Service also followed up that fax with a telephone call to the Emergency Services Team who confirmed that the fax had been received. It appears that in triaging the referral that it was signed off on the basis that Doreen had been admitted to The Great Western Hospital. I heard evidence from a Senior Adult Safeguarding Manager at Wiltshire Council ███████ who confirmed my suspicion that in relation to the self-neglect issues that they would ordinarily have been left for the team at Athelston House to address as that from a common sense point of view would be the most appropriate way forward. There however remained the issue as regards the possible financial abuse by a Carer of Doreen. I am concerned here as regards the procedures in place to ensure that safeguarding referrals are properly investigated and whilst I was satisfied that what happened here did not contribute to Doreen’s death I am concerned that a safeguarding issue was not followed up and in fact was signed off in circumstances when clearly it should not have been . I would like you to look into this matter with a view to reviewing what went wrong and providing assurances as regards what measures may be introduced to minimise the risk of this happening again in the future or if no action is proposed to be taken, why no action is to be taken;
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a mental capacity assessment for a serious and complex decision
Wider context from the report “d) (Wiltshire Health & Care) As part of the evidence I heard that Doreen in the opinion of an Expert Geriatric Psychiatrist, not only had a mental impairment (cognitive impairment more likely with underlying dementia) but also more importantly that in relation to a serious and complex decision to return home she was of the view, in respect of which I accepted, that more likely than not Doreen could not understand her needs and was unable to recognise the risk of refusing the safeguarding recommendations and that in relation to her decision to return home and those associated decisions that she did not have mental capacity. I indicated in my summing up that this was a difficult case but I feel that the training given especially to the Therapy led members of the team did not sufficiently prepare them to deal with very complicated cases such as Doreen’s although that having been said if the advice that had been given had been followed the outcome possibly would have been different. I was however satisfied that had the advice been followed and a capacity test undertaken that Doreen would not have returned home when she did and therefore would not have died when she did. It was also readily apparent to me that members of the Therapy led Team and particularly ███████ was unaware that the safeguarding measures, part of the Mental Capacity Act and in particular the ability to secure either and urgent or standard authorisation for the deprivation of somebody’s liberty was not available where the individual concerned lives in the community and where their care is paid for privately. One witness said those cases can be extremely challenging and essentially those trying to do their best for the individual essentially have to wait for the next crisis to occur before they may be given an opportunity to introduce safeguarding measures. Had the mental impairment been recognised and the mental capacity assessment been carried out revealing that she did not have mental capacity in relation to the serious and complex decision to return home and associated decisions concerning additional safeguarding measures and if Doreen still wished to return home then it may have been in her best interests to have considered Deprivation of Liberty Safeguarding Order. I would hope that this particular case in particular could be used as a specific training case by all organisations involved but I have concerns that there were material gaps in individuals’ knowledge bases.
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer important cognitive assessment information at discharge
Wider context from the report “b) (Great Western Hospital) In considering the evidence when Doreen was discharged from The Great Western Hospital initially on the 21st December 2015, she was sent with a discharge letter and a 4 page Medivo Summary summarising the paramedics’ attendance on the 20th December 2015. Of note that summary did not contain any information that the paramedic had undertaken a 6CIT Cognitive evaluation of Doreen and that she had failed that assessment . One can never guarantee that another document will reflect the information contained in the initial report and therefore a possible way forward could be to ensure in cases where the turnaround through hospital is short that as part of the Discharge Package that it includes a copy of the Paramedic handwritten report that would have been provide to Great Western Hospital when she was admitted. It is however for you to consider how to resolve the concern here that an important bit of information was not provided to the team at Athelston House ;
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training for therapy-led teams handling complex cases
Wider context from the report “d) (Wiltshire Health & Care) As part of the evidence I heard that Doreen in the opinion of an Expert Geriatric Psychiatrist, not only had a mental impairment (cognitive impairment more likely with underlying dementia) but also more importantly that in relation to a serious and complex decision to return home she was of the view, in respect of which I accepted, that more likely than not Doreen could not understand her needs and was unable to recognise the risk of refusing the safeguarding recommendations and that in relation to her decision to return home and those associated decisions that she did not have mental capacity. I indicated in my summing up that this was a difficult case but I feel that the training given especially to the Therapy led members of the team did not sufficiently prepare them to deal with very complicated cases such as Doreen’s although that having been said if the advice that had been given had been followed the outcome possibly would have been different. I was however satisfied that had the advice been followed and a capacity test undertaken that Doreen would not have returned home when she did and therefore would not have died when she did. It was also readily apparent to me that members of the Therapy led Team and particularly ███████ was unaware that the safeguarding measures, part of the Mental Capacity Act and in particular the ability to secure either and urgent or standard authorisation for the deprivation of somebody’s liberty was not available where the individual concerned lives in the community and where their care is paid for privately. One witness said those cases can be extremely challenging and essentially those trying to do their best for the individual essentially have to wait for the next crisis to occur before they may be given an opportunity to introduce safeguarding measures. Had the mental impairment been recognised and the mental capacity assessment been carried out revealing that she did not have mental capacity in relation to the serious and complex decision to return home and associated decisions concerning additional safeguarding measures and if Doreen still wished to return home then it may have been in her best interests to have considered Deprivation of Liberty Safeguarding Order. I would hope that this particular case in particular could be used as a specific training case by all organisations involved but I have concerns that there were material gaps in individuals’ knowledge bases .
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the healthcare-record archiving system to retain and provide records
Wider context from the report “c) (Wiltshire Council, Wiltshire Health & Care and Great Western Hospital) As a general comment, my view in relation to the quality and substance of case notes was that they were poor in quality. My investigation was hampered due to the fact that the Archiving System at Great Western Hospital for Doreen’s therapy led healthcare notes failed in that the notes or at least the scanned images were lost and were not available . Given that some notes were recorded on the Wiltshire Council Care First System and the evidence was that the Healthcare records would not have been significantly different my concerns remain. Crucial and important decisions did not contain any rationale as to why and the basis upon which that decision was being made. As indicated when I summed up the evidence my view is that recording a rationale can act as a check in relation to the decision making process itself as it forces the author to consider the process and information that has led to that decision being made.
I also have concerns in relation to the way MDT’s work and reach decisions. The decisions very much appear in relation to the case decision amongst relevant members of the team as opposed to an individual making the decision based on information provided by relevant team members. There was no leadership. My concern as regards this consensual approach is that no-one actually takes ownership and responsibility for the decision itself and a consensual approach as evidenced in Doreen’s case can in my view lead to a situation whereby there is a false sense of reassurance in believing that nothing more could be done for Doreen that in this case led to wrong decisions being taken.
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of Mental Capacity Act safeguarding measure limitations in privately funded community care
Wider context from the report “d) (Wiltshire Health & Care) As part of the evidence I heard that Doreen in the opinion of an Expert Geriatric Psychiatrist, not only had a mental impairment (cognitive impairment more likely with underlying dementia) but also more importantly that in relation to a serious and complex decision to return home she was of the view, in respect of which I accepted, that more likely than not Doreen could not understand her needs and was unable to recognise the risk of refusing the safeguarding recommendations and that in relation to her decision to return home and those associated decisions that she did not have mental capacity. I indicated in my summing up that this was a difficult case but I feel that the training given especially to the Therapy led members of the team did not sufficiently prepare them to deal with very complicated cases such as Doreen’s although that having been said if the advice that had been given had been followed the outcome possibly would have been different. I was however satisfied that had the advice been followed and a capacity test undertaken that Doreen would not have returned home when she did and therefore would not have died when she did. It was also readily apparent to me that members of the Therapy led Team and particularly ███████ was unaware that the safeguarding measures, part of the Mental Capacity Act and in particular the ability to secure either and urgent or standard authorisation for the deprivation of somebody’s liberty was not available where the individual concerned lives in the community and where their care is paid for privately . One witness said those cases can be extremely challenging and essentially those trying to do their best for the individual essentially have to wait for the next crisis to occur before they may be given an opportunity to introduce safeguarding measures. Had the mental impairment been recognised and the mental capacity assessment been carried out revealing that she did not have mental capacity in relation to the serious and complex decision to return home and associated decisions concerning additional safeguarding measures and if Doreen still wished to return home then it may have been in her best interests to have considered Deprivation of Liberty Safeguarding Order. I would hope that this particular case in particular could be used as a specific training case by all organisations involved but I have concerns that there were material gaps in individuals’ knowledge bases.
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of individual ownership and leadership for MDT decisions
Wider context from the report “c) (Wiltshire Council, Wiltshire Health & Care and Great Western Hospital) As a general comment, my view in relation to the quality and substance of case notes was that they were poor in quality. My investigation was hampered due to the fact that the Archiving System at Great Western Hospital for Doreen’s therapy led healthcare notes failed in that the notes or at least the scanned images were lost and were not available. Given that some notes were recorded on the Wiltshire Council Care First System and the evidence was that the Healthcare records would not have been significantly different my concerns remain. Crucial and important decisions did not contain any rationale as to why and the basis upon which that decision was being made. As indicated when I summed up the evidence my view is that recording a rationale can act as a check in relation to the decision making process itself as it forces the author to consider the process and information that has led to that decision being made.
I also have concerns in relation to the way MDT’s work and reach decisions. The decisions very much appear in relation to the case decision amongst relevant members of the team as opposed to an individual making the decision based on information provided by relevant team members. There was no leadership . My concern as regards this consensual approach is that no-one actually takes ownership and responsibility for the decision itself and a consensual approach as evidenced in Doreen’s case can in my view lead to a situation whereby there is a false sense of reassurance in believing that nothing more could be done for Doreen that in this case led to wrong decisions being taken.
” Open source report
7 Apr 2017 Christina Bernadette Withey · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 5 Failure to keep patient records relating to urine charts View source Failure to accurately measure urine output View source Lack of review of sepsis guidelines against the Acute care toolkit 9: sepsis View source Delays in reviewing patients whose condition has not improved View source Lack of training for locums and other temporary staff View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christina Bernadette Withey · 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
Christina Bernadette Withey was an inpatient at Great Western Hospital when she suffered a stercoral perforation, leading to faecal peritonitis, sepsis and multi-organ failure, and died on 15 September 2015. The concerns included patient record-keeping and urine-output measurement, delays in reviewing patients whose condition had not improved, sepsis guidance, and the training of locum and other temporary staff.
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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep patient records relating to urine charts
Wider context from the report “(1) The keeping of patient records in relation to a urine chart and the accurate measuring of output.
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately measure urine output
Wider context from the report “(1) The keeping of patient records in relation to a urine chart and the accurate measuring of output .
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of review of sepsis guidelines against the Acute care toolkit 9: sepsis
Wider context from the report “(3) Review of the sepsis guidelines in the light of the “Acute care toolkit 9: sepsis” produced by The Royal College of Physicians
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reviewing patients whose condition has not improved
Wider context from the report “(2) The period before a review of a patient is carried out where there has been no improvement in condition .
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training for locums and other temporary staff
Wider context from the report “(4) The training of locums and other temporary staff
” Open source report
11 Jan 2016 Robin Keith Brett · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 2 Failure to detect missed steroid doses View source Lack of alerts identifying patients on long-term steroids 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
Robin Keith Brett · 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
Robin Keith Brett, an 18-year-old man with congenital adrenal hyperplasia, died on 14 June 2014 after being admitted with severe constipation and an addisonian crisis. He did not receive his prescribed steroids, and the concerns identified were that nursing staff failed to notice the missed dose and that prescribing systems lacked an alert for patients taking long-term steroids.
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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to detect missed steroid doses
Wider context from the report “This patient was prescribed steroids appropriately but the nursing staff failed to notice a dose of steroids had been missed . There is no system on the paper drug chart or the electronic prescribing system for alerting medical staff to patients being on long term steroids.
” 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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of alerts identifying patients on long-term steroids
Wider context from the report “This patient was prescribed steroids appropriately but the nursing staff failed to notice a dose of steroids had been missed. There is no system on the paper drug chart or the electronic prescribing system for alerting medical staff to patients being on long term steroids .
” Open source report
20 Feb 2015 Richard Jeffrey Jones · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 3 Failure to record primary responsibility for patient care during transfers of care View source Failure to share patient information accurately with other agencies involved in care View source Failure to record information obtained from mental health patients, including perceived risk and assessment urgency 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
Richard Jeffrey 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
Richard Jeffrey Jones was at home alone and, during 14 to 15 October 2012, voluntarily ingested a quantity of tramadol that led to loss of consciousness, respiratory depression and aspiration of gastric contents, causing his death. The report raised concerns about recording and sharing information on risk and urgency, and about identifying primary responsibility when care was transferred between mental health services.
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 Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record primary responsibility for patient care during transfers of care
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of 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 Great Western Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share patient information accurately with other agencies involved in care
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency .
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of 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 Great Western Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record information obtained from mental health patients, including perceived risk and assessment urgency
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment .
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care.
” 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