Recipient

Hereford County Hospital

First report 18 Apr 2023•Latest report 19 Jul 2024

Recipient record

Reports, concerns and published responses

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

Reports: 2
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

19 Jul2024
Herefordshire
Concerns raised2
1. Failure to complete falls assessments before routinely erecting bed rails
2. Unsatisfactory procedures for establishing whether call bells are working
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

Rita Howells · 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

Rita Howells was transferred to Bromyard Hospital for rehabilitation and discharge planning, later became confused and agitated, fell from her bed, and was found to have an intracerebral haemorrhage. The concerns identified were that bed rails were routinely erected before a falls assessment, contrary to policy, and that procedures for establishing whether a call bell was working were unsatisfactory.

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 Hereford County Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete falls assessments before routinely erecting bed rails
Wider context from the report
“(1) Contrary to Policy as advised, bed rails are routinely erected before Falls Assessment ”
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 Hereford County Hospital; that does not assign responsibility.
PFD Monitor interpretation
Unsatisfactory procedures for establishing whether call bells are working
Wider context from the report
“(2) The procedures to establish whether a call bell is working are unsatisfactory ”
Open source report
18 Apr2023
Herefordshire
Concerns raised5
1. Failure to provide appropriate senior oversight of patient assessment
2. Inadequate monitoring following triage
3. Delays in communication with next of kin
1. Failure to consistently adopt an appropriate triage system in Accident and Emergency
2. Delays in responsible sign-off of S.I. reports
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

Keith Hodson · 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

Keith Hodson had a complex medical history, with delays before an ambulance was called, in ambulance attendance, on hospital admission and in receiving appropriate treatment. Concerns included failure to consistently use an appropriate triage system in Accident and Emergency, inadequate escalation and monitoring, insufficient senior oversight, delays in signing off serious incident reports, and untimely communication with the next of kin.

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 Hereford County Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide appropriate senior oversight of patient assessment
Wider context from the report
“(3) I am advised that on occasion appropriate senior oversight does not occur, this is required to identify when a patient has not been appropriately assessed. ”
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 Hereford County Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inadequate monitoring following triage
Wider context from the report
“Evidence given at the Inquest identified: The Ambulance crew pre-alerted A and E, but the patient was not triaged using the Manchester Triage System, resulting in missed opportunities to identify the patient’s clinical priority. There was subsequently inadequate monitoring. The degree of timely candour with the family is unclear and clarification is required in this regard. It is acknowledged that delays of substance occurred prior to attendance at A and E, but this increases the importance of early assessment and triage procedure. ”
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 Hereford County Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in communication with next of kin
Wider context from the report
“(5) Communication with the next of kin appears not to have occurred in a timely fashion. ”
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 Hereford County Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to consistently adopt an appropriate triage system in Accident and Emergency
Wider context from the report
“(1) I am advised that an appropriate Triage System is not always adopted in practice at Accident and Emergency. (2) Without the adoption of a Triage System taking place escalation of care cannot meaningfully take place. ”
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 Hereford County Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in responsible sign-off of S.I. reports
Wider context from the report
“(4) S.I. reports are not signed off in a timely fashion by a responsible individual. ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Failure to complete falls assessments before routinely erecting bed rails

Unsatisfactory procedures for establishing whether call bells are working

Concerns raised5

Failure to provide appropriate senior oversight of patient assessment

Inadequate monitoring following triage

Delays in communication with next of kin

Failure to consistently adopt an appropriate triage system in Accident and Emergency

Delays in responsible sign-off of S.I. reports