27 Nov 2013 Edna Elsie Mary Eden · Prevention of Future Deaths report Berkshire
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Concerns raised 10 Failure to escalate unresolved clinical review access problems to senior staff View source Insufficient information in clinical handovers View source Delays in medical review of admitted patients View source Delays in medical review of admitted patients View source Failure of junior staff to escalate clinical concerns to senior staff View source Insufficient frequency of nursing observations for uncleared patients View source Failure to base patient-review prioritisation on sufficiently detailed clinical information View source Failure to calculate EDD scores accurately and trigger required Doctor review View source Failure to provide prescribed antibiotic cover pending medical review View source Unavailability of Doctors for nursing requests for review View source See 7 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Edna Elsie Mary Eden · 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
Edna Elsie Mary Eden, who had been living independently, was admitted to hospital after feeling unwell and reporting recent right-sided chest pain. She remained in A&E and the AMU for approximately fourteen and a half hours before being seen by a doctor, then arrested and could not be revived. The report identified missed opportunities involving delayed medical review, failure to recognise or escalate abnormal findings, inadequate communication, incorrect observation scoring, and lack of antibiotic cover.
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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 Heatherwood and Wexham Park Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate unresolved clinical review access problems to senior staff
Wider context from the report “(3) Nursing staff were not able to make contact with Doctors to review Mrs Eden. When this continued, the problem was not escalated to more senior staff .
” 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 Heatherwood and Wexham Park Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient information in clinical handovers
Wider context from the report “(4) Clinicians were taking decisions over priority of seeing patients based only on a very vague description of Mrs Eden’s condition. Information at handovers appeared very limited .
” 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 Heatherwood and Wexham Park Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in medical review of admitted patients
Wider context from the report “(6) An elderly patient who was admitted with a covering letter describing recent chest pain was not seen by a Doctor for a total of fourteen and a half hours .
” 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 Heatherwood and Wexham Park Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in medical review of admitted patients
Wider context from the report “(1) Mrs Eden was admitted having been prescribed antibiotics by her GP. She was not provided with further antibiotic cover pending being seen by a Doctor and that was unduly delayed meaning that she went fourteen and a half hours without her prescribed medication .
” 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 Heatherwood and Wexham Park Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of junior staff to escalate clinical concerns to senior staff
Wider context from the report “(5) Junior staff on a very busy shift appeared reluctant, or ignorant of the procedures, to escalate concerns to more senior staff to address a significant backlog that had developed.
” 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 Heatherwood and Wexham Park Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient frequency of nursing observations for uncleared patients
Wider context from the report “(2) The nursing observation chart suggested infrequent observations for a patient who had not yet been clerked by a Doctor. The EDD score was wrongly calculated which meant an escalation of Doctor review was not carried 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 Heatherwood and Wexham Park Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to base patient-review prioritisation on sufficiently detailed clinical information
Wider context from the report “(4) Clinicians were taking decisions over priority of seeing patients based only on a very vague description of Mrs Eden’s condition . Information at handovers appeared very limited.
” 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 Heatherwood and Wexham Park Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to calculate EDD scores accurately and trigger required Doctor review
Wider context from the report “(2) The nursing observation chart suggested infrequent observations for a patient who had not yet been clerked by a Doctor. The EDD score was wrongly calculated which meant an escalation of Doctor review was not carried 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 Heatherwood and Wexham Park Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prescribed antibiotic cover pending medical review
Wider context from the report “(1) Mrs Eden was admitted having been prescribed antibiotics by her GP. She was not provided with further antibiotic cover pending being seen by a Doctor and that was unduly delayed meaning that she went fourteen and a half hours without her prescribed medication.
” 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 Heatherwood and Wexham Park Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of Doctors for nursing requests for review
Wider context from the report “(3) Nursing staff were not able to make contact with Doctors to review Mrs Eden . When this continued, the problem was not escalated to more senior staff.
” 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