Holy Cross Hospital

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First report 19 Apr 2022•Latest report 19 Apr 2022

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 1
Published responses: 100%
Concerns addressed: 3
Stated actions: 4

Concerns and recipient responses

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

19 Apr2022
Surrey
Concerns raised3
1. Incomplete recording of vital signs
2. Failure to record the actual results of vital observations
3. Failure to escalate NEWS2 scores and abnormal vital observations
Actions described in response 4
1. Action
  Train staff on the Managing a Deteriorating Patient policy after implementation.
2. Action
  Adopt and implement the Managing a Deteriorating Patient policy, including monitoring and escalation guidance and regular NEWS2 baseline collection.
3. Action
  Repeat clinical decision-making, patient-risk, NEWS2 and sepsis training for relevant ward staff.
1. Action
  Implement an electronic patient record system requiring measured values instead of narrative descriptions.
AI-generated summary

Richard Scott-Powell · 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 Scott-Powell, aged 61, suffered a spinal cord injury after a fall at home in March 2020 and later died from COVID-19 pneumonia at Holy Cross Hospital on 18 January 2021. The principal concerns were the lack of recorded escalation of high NEWS2 scores and abnormal vital signs, incomplete recording of observations, and uncertainty about whether appropriate policies and training were in place for taking, recording and escalating vital observations.

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 Holy Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Incomplete recording of vital signs
Wider context from the report
“The court heard evidence that following Mr Scott-Powell’s positive COVID-19 test on 11 January 2021 a NEWS2 Observation Chart was commenced on 13 January 2021. On that day he initially had a NEWS2 score of 10 and subsequently a NEWS2 score of 5. There is no clear evidence in the hospital records to show that these scores prompted an increased level of frequency of observations or that they were escalated, whether that be to Mr Scott-Powell’s GP or otherwise. Thereafter, there are no further NEWS2 charts in Mr Scott-Powell’s records, albeit some of his vital signs are recorded in the daily notes. On a number of occasions, the notes only record that ‘vital signs are okay’ without specifying what the vital signs actually were. In respect of some of the vital signs that were recorded, Dr ████████, a GP at Grayshott Surgery which is the GP Surgery for patients at Holy Cross Hospital, gave evidence that some of them fell outside normal or expected parameters. Again, there is no evidence in the notes to show that these observations were escalated prior to Mr Scott-Powell’s death. Given Mr Scott-Powell’s pre-existing conditions and vulnerabilities the Court was not persuaded, on the balance of probabilities, that any escalation would have resulted in treatment, which would have materially improved Mr Scott-Powell’s clinical progress. 1. There is no recorded escalation of Mr Scott-Powell’s NEWS2 scores on 13 January 2021; 2. During the period from 14 January 2021 onwards, only some of his vital signs are recorded, some of which fall outside normal parameters. There is no recorded escalation of these observations in the record. 3. During the period from 14 January 2021 onwards, a number of entries record that his vital signs were okay without detailing the actual outcome of those observations. The Coroner is concerned this may not be a safe practice in that it makes it difficult for the clinical team to track progress and identify any trends. Dr ████████, a Consultant in Rehabilitation Medicine at Holy Cross Hospital and Dr ████████, GP, both attended Court to give evidence and whilst they did their best to assist the Court on these matters, it remains unclear to the Court as to whether there are sufficient and appropriate policies are in place, which are well understood by the staff, in relation to the taking, recording and escalation of vital observations at Holy Cross Hospital. Accordingly, the Coroner considers that a review of these matters should be carried out to identify whether additional policies/procedures and or/training is required. ”
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 Holy Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to record the actual results of vital observations
Wider context from the report
“The court heard evidence that following Mr Scott-Powell’s positive COVID-19 test on 11 January 2021 a NEWS2 Observation Chart was commenced on 13 January 2021. On that day he initially had a NEWS2 score of 10 and subsequently a NEWS2 score of 5. There is no clear evidence in the hospital records to show that these scores prompted an increased level of frequency of observations or that they were escalated, whether that be to Mr Scott-Powell’s GP or otherwise. Thereafter, there are no further NEWS2 charts in Mr Scott-Powell’s records, albeit some of his vital signs are recorded in the daily notes. On a number of occasions, the notes only record that ‘vital signs are okay’ without specifying what the vital signs actually were. In respect of some of the vital signs that were recorded, Dr ████████, a GP at Grayshott Surgery which is the GP Surgery for patients at Holy Cross Hospital, gave evidence that some of them fell outside normal or expected parameters. Again, there is no evidence in the notes to show that these observations were escalated prior to Mr Scott-Powell’s death. Given Mr Scott-Powell’s pre-existing conditions and vulnerabilities the Court was not persuaded, on the balance of probabilities, that any escalation would have resulted in treatment, which would have materially improved Mr Scott-Powell’s clinical progress. 1. There is no recorded escalation of Mr Scott-Powell’s NEWS2 scores on 13 January 2021; 2. During the period from 14 January 2021 onwards, only some of his vital signs are recorded, some of which fall outside normal parameters. There is no recorded escalation of these observations in the record. 3. During the period from 14 January 2021 onwards, a number of entries record that his vital signs were okay without detailing the actual outcome of those observations. The Coroner is concerned this may not be a safe practice in that it makes it difficult for the clinical team to track progress and identify any trends. Dr ████████, a Consultant in Rehabilitation Medicine at Holy Cross Hospital and Dr ████████, GP, both attended Court to give evidence and whilst they did their best to assist the Court on these matters, it remains unclear to the Court as to whether there are sufficient and appropriate policies are in place, which are well understood by the staff, in relation to the taking, recording and escalation of vital observations at Holy Cross Hospital. Accordingly, the Coroner considers that a review of these matters should be carried out to identify whether additional policies/procedures and or/training is required. ”
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 Holy Cross Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to escalate NEWS2 scores and abnormal vital observations
Wider context from the report
“The court heard evidence that following Mr Scott-Powell’s positive COVID-19 test on 11 January 2021 a NEWS2 Observation Chart was commenced on 13 January 2021. On that day he initially had a NEWS2 score of 10 and subsequently a NEWS2 score of 5. There is no clear evidence in the hospital records to show that these scores prompted an increased level of frequency of observations or that they were escalated, whether that be to Mr Scott-Powell’s GP or otherwise. Thereafter, there are no further NEWS2 charts in Mr Scott-Powell’s records, albeit some of his vital signs are recorded in the daily notes. On a number of occasions, the notes only record that ‘vital signs are okay’ without specifying what the vital signs actually were. In respect of some of the vital signs that were recorded, Dr ████████, a GP at Grayshott Surgery which is the GP Surgery for patients at Holy Cross Hospital, gave evidence that some of them fell outside normal or expected parameters. Again, there is no evidence in the notes to show that these observations were escalated prior to Mr Scott-Powell’s death. Given Mr Scott-Powell’s pre-existing conditions and vulnerabilities the Court was not persuaded, on the balance of probabilities, that any escalation would have resulted in treatment, which would have materially improved Mr Scott-Powell’s clinical progress. 1. There is no recorded escalation of Mr Scott-Powell’s NEWS2 scores on 13 January 2021; 2. During the period from 14 January 2021 onwards, only some of his vital signs are recorded, some of which fall outside normal parameters. There is no recorded escalation of these observations in the record. 3. During the period from 14 January 2021 onwards, a number of entries record that his vital signs were okay without detailing the actual outcome of those observations. The Coroner is concerned this may not be a safe practice in that it makes it difficult for the clinical team to track progress and identify any trends. Dr ████████, a Consultant in Rehabilitation Medicine at Holy Cross Hospital and Dr ████████, GP, both attended Court to give evidence and whilst they did their best to assist the Court on these matters, it remains unclear to the Court as to whether there are sufficient and appropriate policies are in place, which are well understood by the staff, in relation to the taking, recording and escalation of vital observations at Holy Cross Hospital. Accordingly, the Coroner considers that a review of these matters should be carried out to identify whether additional policies/procedures and or/training is required. ”
Open source report
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
Train staff on the Managing a Deteriorating Patient policy after implementation.

Verbatim wording from the response
“• have written a policy on ‘Managing a Deteriorating Patient’, which includes a decision tree for monitoring and escalation. The policy proposes collecting regular NEWS2 baseline data for each Holy Cross patient, taking into account that many patients will routinely fall outside of the normal range. The draft policy has been reviewed by our Consultant in Rehabilitation Medicine and by the lead duty doctor to Holy Cross (from Grayshott surgery), ahead of adoption by our Clinical Governance Medical Research and Ethics Committee on 25th July. Following its implementation, the policy will be subject to review and evaluation. Staff will receive training on the policy.”

Source location
Response from Holy Cross Hospital
Page 2 · response
Published 27 April 2022
Open published response
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
Adopt and implement the Managing a Deteriorating Patient policy, including monitoring and escalation guidance and regular NEWS2 baseline collection.

Verbatim wording from the response
“• have written a policy on ‘Managing a Deteriorating Patient’, which includes a decision tree for monitoring and escalation. The policy proposes collecting regular NEWS2 baseline data for each Holy Cross patient, taking into account that many patients will routinely fall outside of the normal range. The draft policy has been reviewed by our Consultant in Rehabilitation Medicine and by the lead duty doctor to Holy Cross (from Grayshott surgery), ahead of adoption by our Clinical Governance Medical Research and Ethics Committee on 25th July. Following its implementation, the policy will be subject to review and evaluation. Staff will receive training on the policy.”

Source location
Response from Holy Cross Hospital
Page 2 · response
Published 27 April 2022
Open published response
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
Repeat clinical decision-making, patient-risk, NEWS2 and sepsis training for relevant ward staff.

Verbatim wording from the response
“Training (clinical decision making / patients at risk) - As part of a wider range of learning and development courses, training is provided to the ward team to facilitate clinical decision-making and escalation as follows: Clinical Decision Making (Registered Nurses), Identifying Patients at Risk (Health Care Assistants), NEWS2 (Registered Nurses and HCAs) and Sepsis (Registered Nurses and HCAs). The first two courses are in-house, with NEWS2 and Sepsis being online courses (containing standard methodologies/protocols). We are in the process of repeating training in these areas for all relevant staff.”

Source location
Response from Holy Cross Hospital
Page 1 · response
Published 27 April 2022
Open published response
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 an electronic patient record system requiring measured values instead of narrative descriptions.

Verbatim wording from the response
“We are also implementing an Electronic Patient Record System in the second half of 2022/23. This will provide better standardisation over paper records, and will require measured values to be entered (rather than a narrative ‘okay’).”

Source location
Response from Holy Cross Hospital
Page 2 · response
Published 27 April 2022
Open published response