26 Jun 2024 Brian John COLBY · Prevention of Future Deaths report Inner North London
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Concerns raised 6 Failure of clinical communication to convey urgent investigation instructions View source Delays in communicating and acting on urgent investigation instructions for deteriorating patients View source Use of unreliable text messaging for escalation of serious patient concerns View source Lack of clear protocols for escalation of deteriorating patients View source Failure to record urgent clinical assessments and plans promptly View source Failure to ensure resident doctors understand their authority to commence CT scan ordering View source See 3 more concerns
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Brian John COLBY · 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
Brian Colby was an in-patient recovering from elective surgery and receiving treatment for aspiration pneumonia when he suffered a spontaneous catastrophic intracranial event on 16 September 2023; he died later that evening after being transferred for assessment and placed on a palliative care pathway. The principal concerns were delays and ineffective communication in recognising and escalating his deterioration, arranging an urgent CT scan, communicating clinical plans, and recording urgent matters. The report also raised concerns about unclear escalation and record-keeping procedures and whether further training had adequately addressed clinicians’ authority to initiate CT scan arrangements.
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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 HCA Healthcare UK; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical communication to convey urgent investigation instructions
Wider context from the report “(2) At or about 11:00 on 16 September 2023, Mr Colby was routinely reviewed by a medical consultant (i.e. the review did not take place because Mr Colby’s condition had been escalated). The medical consultant was immediately concerned by the apparent deterioration in Mr Colby’s condition and, as part of a wider plan, the medical consultant requested that a CT head scan should be carried out urgently or as soon as possible. This request was misunderstood and therefore not acted upon by the ICU fellow .
The medical consultant did not record his assessment of, and plan for, Mr Colby until approximately 20:00 that evening. This meant that the entire plan was not available for others to refer back to, if required.
I heard that the record keeping system is currently a hybrid system, comprising some manuscript and some computerised records. I also heard that HCA Healthcare is currently mid-way through commissioning a new patient records system at significant cost.
Notwithstanding the clearly significant ongoing investment in new record keeping software, my concern is not about record keeping per se, it is about communication between clinical staff and expectations in terms of plans of care etc. Both points (1) and (2) involve ineffective communication of clinicians at many levels.
In addition, while I accept that clinical staff may not always be able to complete contemporaneous records and may have to write some records in retrospect, there is no clear procedure or expectation in relation to record keeping, particularly in relation to urgent clinical matters, or alternatively, any procedures or expectations are not always followed.
” 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 HCA Healthcare UK; that does not assign responsibility.
PFD Monitor interpretation Delays in communicating and acting on urgent investigation instructions for deteriorating patients
Wider context from the report “(5) The effective instruction to send Mr Colby for an urgent CT scan was at 13:19 on 16 September 2023, over two hours after an instruction for an urgent or as soon as possible CT head scan was given by a medical consultant (albeit it, this instruction was misunderstood) and over three hours after a CT head scan was first clinically indicated.
This raises further concern in relation to communication and the escalation of deteriorating patients .
The evidence was such that any delays in Mr Colby’s escalation and treatment were not causative of his death, but of course, that might not be the case for another 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 HCA Healthcare UK; that does not assign responsibility.
PFD Monitor interpretation Use of unreliable text messaging for escalation of serious patient concerns
Wider context from the report “(4) When an ICU fellow formed the view that Mr Colby’s clinical deterioration did warrant escalation to the on-call ICU consultant, this was done by way of sending the consultant a text message at 12:42 on 16 September 2023. It seems to me that the sending of a text message is not likely to be the most effective way of escalating serious (and presumably urgent) concerns about patients . It carries inherent risks of the message not being delivered and/or not being seen by the recipient in a timely manner .
My concern relates to the efficacy of, or possibly the adherence to, any procedures or protocols for the escalation of deteriorating patients.
” 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 HCA Healthcare UK; that does not assign responsibility.
PFD Monitor interpretation Lack of clear protocols for escalation of deteriorating patients
Wider context from the report “(1) At or about 10:00 on 16 September 2023, Mr Colby’s vital signs and observations showed a drop in his Glasgow Coma Score from 15/15 (at 09:00) to 11/15, and a clinically significant rise in his blood pressure. I heard evidence that this change in his vital signs and observations was enough to warrant requesting a CT scan to ascertain the cause or causes of the change in clinical presentation. Despite this, I found that this was not escalated as a cause for concern at the time. I heard that the on-call consultant for the intensive care unit (ICU) was not made aware of any deterioration in Mr Colby’s presentation until 12:42 that afternoon.
The concern here is that there did not appear to be any, or any clear, protocol(s) in place for the escalation of a deteriorating 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 HCA Healthcare UK; that does not assign responsibility.
PFD Monitor interpretation Failure to record urgent clinical assessments and plans promptly
Wider context from the report “(2) At or about 11:00 on 16 September 2023, Mr Colby was routinely reviewed by a medical consultant (i.e. the review did not take place because Mr Colby’s condition had been escalated). The medical consultant was immediately concerned by the apparent deterioration in Mr Colby’s condition and, as part of a wider plan, the medical consultant requested that a CT head scan should be carried out urgently or as soon as possible. This request was misunderstood and therefore not acted upon by the ICU fellow.
The medical consultant did not record his assessment of, and plan for, Mr Colby until approximately 20:00 that evening. This meant that the entire plan was not available for others to refer back to, if required.
I heard that the record keeping system is currently a hybrid system, comprising some manuscript and some computerised records. I also heard that HCA Healthcare is currently mid-way through commissioning a new patient records system at significant cost.
Notwithstanding the clearly significant ongoing investment in new record keeping software, my concern is not about record keeping per se, it is about communication between clinical staff and expectations in terms of plans of care etc. Both points (1) and (2) involve ineffective communication of clinicians at many levels.
In addition, while I accept that clinical staff may not always be able to complete contemporaneous records and may have to write some records in retrospect, there is no clear procedure or expectation in relation to record keeping, particularly in relation to urgent clinical matters , or alternatively, any procedures or expectations are not always followed .
” 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 HCA Healthcare UK; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure resident doctors understand their authority to commence CT scan ordering
Wider context from the report “(3) On 16 September 2023, the ICU fellow did not arrange a CT scan their self for Mr Colby. I heard that this was because the ICU fellow was working under the mistaken belief that only a consultant could order a CT scan in the private sector . Other evidence confirmed that this was clearly not the case.
I heard evidence that, “the authority of resident doctors to commence the scan ordering process in advance of a consultant discussion has now been re-emphasised across the Resident Doctor Training Group.” However, when I heard evidence from the ICU fellow, on 22 May 2024, that clinician remained of the view that they did not have the authority to authorise/commence a CT scan .
There was a delay in Mr Colby being sent for a scan as a result, albeit there were other delays for different reasons.
I am not reassured that the additional training in this regard is having the desired effect and consider that the risk may well remain .
” Open source report
3 Feb 2017 ROBERT ENTENMAN · Prevention of Future Deaths report London Inner (South)
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Concerns raised 4 Delays in communicating suction catheter difficulties to doctors View source Delays in identifying and replacing blocked endotracheal tubes View source Failure to monitor humidifier operation and temperature View source Lack of a humidifier alarm indicating when the machine is turned off 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.
×
AI-generated summary
ROBERT ENTENMAN · 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
Robert Entenman was an intubated intensive care patient whose humidifier was turned off from around 12.00pm on 22 May 2015 until 6.00am on 23 May 2015. A mucus plug blocked his endotracheal tube, leading to cardiac arrest shortly after 6.00am; he died on 30 May 2015. Concerns included failures to observe that the humidifier was off, the absence of an alarm on the humidifier, delays in identifying and replacing the blocked tube, and possible delays in communicating suction difficulties to doctors.
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 HCA Healthcare UK; that does not assign responsibility.
PFD Monitor interpretation Delays in communicating suction catheter difficulties to doctors
Wider context from the report “(3) There were delays in identifying that the endotracheal tube had become blocked between 5.32 and 6.00am on 23 May 2015, and thus replacing it earlier. There may have been further such delays after 6.00 am. There may have been a delay by the nursing staff in providing information about difficulties with the suction catheter to the doctors who arrived after the cardiac arrest call was put out.
” 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 HCA Healthcare UK; that does not assign responsibility.
PFD Monitor interpretation Delays in identifying and replacing blocked endotracheal tubes
Wider context from the report “(3) There were delays in identifying that the endotracheal tube had become blocked between 5.32 and 6.00am on 23 May 2015, and thus replacing it earlier . There may have been further such delays after 6.00 am . There may have been a delay by the nursing staff in providing information about difficulties with the suction catheter to the doctors who arrived after the cardiac arrest call was put out.
” 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 HCA Healthcare UK; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor humidifier operation and temperature
Wider context from the report “(1) Three nurses cared for Mr Entenman between 12.00pm on 22 May 2015 and 6.00am on 23 May 2015. During that time they did not observe that the humidifier had been turned off , either handovers that took place between them or each hour when they should have recorded the temperature reading from the humidifier .
” 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 HCA Healthcare UK; that does not assign responsibility.
PFD Monitor interpretation Lack of a humidifier alarm indicating when the machine is turned off
Wider context from the report “(2) The humidifier machine does not have an alarm on it, to indicate when the machine has been turned off .
” 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