27 Mar 2025 William David Patrick HEWES · Prevention of Future Deaths report Inner North London
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Concerns raised 1 Delays in providing necessary treatment after recognition of a life-threatening condition View source
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William David Patrick HEWES · 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
William David Patrick HEWES was a fit and healthy young man who died from meningococcal septicaemia. Although his life-threatening condition was recognised immediately at hospital, he did not receive the necessary treatment as promptly as he should have, and the report identified a need to share the learning nationally.
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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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in providing necessary treatment after recognition of a life-threatening condition
Wider context from the report “William’s life threatening condition was recognised immediately he attended hospital, but he did not receive the necessary treatment as promptly as he should have done . The cause of the delay was multi factorial.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deliver closed-loop communication training for resident doctors through the Regional Trainee Teaching programme.
Verbatim wording from the response “2) One of our local actions was to deliver SIM (simulation) training to clinical staff. Simulation training is a tool used to gain practical experience, make informed decisions and refine their performance within controlled settings. The SIM training is focused on ensuring closed loop communication / direct instruction to team members when managing sepsis and shock in emergency situations. The plan is to develop this and deliver it on our Regional Trainee Teaching programme to resident doctors on managing human factors within healthcare. This course runs regularly throughout the year, we are aiming to incorporate the learning on closed loop communication into the next programme. The training runs 3 to 4 times a year.” Source location Response from Homerton University Hospital NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue piloting Martha’s Rule, meeting other pilot sites and sharing implementation learning and data with NHS England.
Verbatim wording from the response “1) The Trust are one of the pilot sites for the first phase in implementing Martha’s Rule. This is a major patient safety initiative providing patients and families with a way to seek an urgent review if they are concerned about a loved one’s deterioration. Part of this first phase is to help the NHS to devise and agree a standardised approach to all three elements of Martha’s Rule (ahead of scaling up to further sites in England in the following years). Once fully” Source location Response from Homerton University Hospital NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver simulation training to clinical staff on closed-loop communication and direct instruction during emergency management of sepsis and shock.
Verbatim wording from the response “2) One of our local actions was to deliver SIM (simulation) training to clinical staff. Simulation training is a tool used to gain practical experience, make informed decisions and refine their performance within controlled settings. The SIM training is focused on ensuring closed loop communication / direct instruction to team members when managing sepsis and shock in emergency situations. The plan is to develop this and deliver it on our Regional Trainee Teaching programme to resident doctors on managing human factors within healthcare. This course runs regularly throughout the year, we are aiming to incorporate the learning on closed loop communication into the next programme. The training runs 3 to 4 times a year.” Source location Response from Homerton University Hospital NHS Trust
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11 Oct 2024 Kingsley Efosa Imafidon · Prevention of Future Deaths report North London
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Concerns raised 4 Lack of consideration of additional post-operative monitoring and requirements for patients with HbSS View source Failure of the elective liver biopsy SOP to account for patients with other pathologies such as HbSS View source Lack of liaison between care teams about HbSS-relevant matters before liver biopsy View source Failure of liver biopsy clinical guidelines to provide guidance for patients with other pathologies such as HbSS View source See 1 more concern
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Kingsley Efosa Imafidon · 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
Kingsley Efosa Imafidon, who had homozygous sickle cell disease and suspected liver cirrhosis, underwent a liver biopsy on 29 November 2023. He was found unresponsive at home on 2 December 2023, and the post-mortem examination found extensive fresh haemorrhage into the peritoneal cavity following the biopsy. The concerns included lack of apparent liaison about the relevance of his sickle cell disease, insufficient consideration of additional monitoring, and gaps in the biopsy guidance and procedure for patients with conditions such as HbSS.
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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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consideration of additional post-operative monitoring and requirements for patients with HbSS
Wider context from the report “• There was no apparent liaison between the teams involved in Kingsley's care to consider any matters that may be relevant to his HbSS prior to the biopsy being carried out;
• The Trust’s Standard Operating Procedure (“SOP”) for Elective Liver Biopsy does not appear to give consideration to patients with other pathologies such as HbSS;
• There was no apparent consideration given to potential additional post-operative monitoring or requirements for a patient with HbSS ;
• The Trust’s SOP refers to a document titled “Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology” (Neuberger J, Patel J, Caldwell H et al. Gut 2020) which provides advice on liver biopsy techniques, methods and aftercare etc. These guidelines do not appear to give consideration (and therefore guidance) in relation to the use of liver biopsy for patients with other pathologies such as HbSS.
” 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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the elective liver biopsy SOP to account for patients with other pathologies such as HbSS
Wider context from the report “• There was no apparent liaison between the teams involved in Kingsley's care to consider any matters that may be relevant to his HbSS prior to the biopsy being carried out;
• The Trust’s Standard Operating Procedure (“SOP”) for Elective Liver Biopsy does not appear to give consideration to patients with other pathologies such as HbSS ;
• There was no apparent consideration given to potential additional post-operative monitoring or requirements for a patient with HbSS;
• The Trust’s SOP refers to a document titled “Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology” (Neuberger J, Patel J, Caldwell H et al. Gut 2020) which provides advice on liver biopsy techniques, methods and aftercare etc. These guidelines do not appear to give consideration (and therefore guidance) in relation to the use of liver biopsy for patients with other pathologies such as HbSS.
” 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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of liaison between care teams about HbSS-relevant matters before liver biopsy
Wider context from the report “• There was no apparent liaison between the teams involved in Kingsley's care to consider any matters that may be relevant to his HbSS prior to the biopsy being carried out ;
• The Trust’s Standard Operating Procedure (“SOP”) for Elective Liver Biopsy does not appear to give consideration to patients with other pathologies such as HbSS;
• There was no apparent consideration given to potential additional post-operative monitoring or requirements for a patient with HbSS;
• The Trust’s SOP refers to a document titled “Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology” (Neuberger J, Patel J, Caldwell H et al. Gut 2020) which provides advice on liver biopsy techniques, methods and aftercare etc. These guidelines do not appear to give consideration (and therefore guidance) in relation to the use of liver biopsy for patients with other pathologies such as HbSS.
” 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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of liver biopsy clinical guidelines to provide guidance for patients with other pathologies such as HbSS
Wider context from the report “• There was no apparent liaison between the teams involved in Kingsley's care to consider any matters that may be relevant to his HbSS prior to the biopsy being carried out;
• The Trust’s Standard Operating Procedure (“SOP”) for Elective Liver Biopsy does not appear to give consideration to patients with other pathologies such as HbSS;
• There was no apparent consideration given to potential additional post-operative monitoring or requirements for a patient with HbSS;
• The Trust’s SOP refers to a document titled “Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology” (Neuberger J, Patel J, Caldwell H et al. Gut 2020) which provides advice on liver biopsy techniques, methods and aftercare etc. These guidelines do not appear to give consideration (and therefore guidance) in relation to the use of liver biopsy for patients with other pathologies such as HbSS .
” 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 the Elective Liver Biopsy SOP when further guidance is issued by the relevant professional bodies.
Verbatim wording from the response “The Trust will of course review its SOP in light of any further guidance produced by The British Society of Gastroenterology, The Royal College of Radiologists and The Royal College of Pathology.” Source location Response from Homerton Hospital
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the MDT approach and highlight the updated liver biopsy SOP to referring and booking clinicians through departmental communications and procedure-related emails.
Verbatim wording from the response “The need to adopt a MDT approach in complex cases has been disseminated across the gastroenterology department, which is the main department referring patients for biopsies. The Trust has reviewed the process of biopsy referrals, the liver biopsy pre-assessment clinic and the patient information leaflet. This has led to the creation of a template on Electronic Patient Record (EPR) for use in the pre-assessment clinic.” Source location Response from Homerton Hospital
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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 Elective Liver Biopsy SOP to require enhanced risk assessment, specialist MDT discussion, pre-assessment, relevant monitoring, and reference to current professional guidance.
Verbatim wording from the response “The Trust’s Elective Liver Biopsy Standard Operating procedure (SOP) has been reviewed and updated in light of the concerns raised at the inquest, and the latest version was sent to Emergency Care, Medicine and Rehabilitation Services (EMRS) clinical governance meeting which was held on November 8. Within the updated SOP, Section 3 entitled ‘Vetting of Referrals’ has been amended to read as follows:” Source location Response from Homerton Hospital
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14 Jul 2023 Phoenix Grace CHAPMAN · Prevention of Future Deaths report Inner North London
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Concerns raised 2 Lack of shared understanding among clinicians about the correct protocol View source Failure to ensure that midwives’ views and differing opinions about precipitous labour are communicated and addressed View source
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AI-generated summary
Phoenix Grace CHAPMAN · 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
Phoenix Grace Chapman was born unexpectedly at home and died following cord compression during the second stage of labour. The report identified concerns about differing understandings among clinicians regarding the appropriate response to precipitous labour and about midwives’ views not being sufficiently heard before protocols were established.
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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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding among clinicians about the correct protocol
Wider context from the report “The reason I make a report to the Homerton, is because it seemed to me at inquest that there were two matters that had not yet been resolved.
i) At inquest, there was not a shared understanding among the clinicians within the trust about how such a situation should be approached .
The obstetricians were clear that, given her very high risk status, Phoenix’ mum needed to come in to hospital as soon as she showed the first signs of labour. And even if she had started to deliver, she could still only be treated effectively and Phoenix given the best chance of a good outcome in hospital.
However, some of the midwives felt strongly that, when Phoenix’ dad could see the baby’s leg emerge, they should have been allowed to go out to the home to give whatever assistance they could.
All the clinicians need have the same understanding of the correct protocol.
ii) A related point is that, before Phoenix was born, some of the midwives felt that their views of what should happen in the event of precipitous labour had not been taken seriously.
If they are to be effective in their role, and if necessary to understand why a protocol does fully reflect their feelings and views, the midwives’ ability to communicate with senior management needs to be enhanced.
If the team as a whole is to move forward in a way that provides the best possible care for women in labour and their babies, questions and differing opinions need to be in some way acknowledged and dealt with before the correct protocol can be embedded.
” 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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that midwives’ views and differing opinions about precipitous labour are communicated and addressed
Wider context from the report “The reason I make a report to the Homerton, is because it seemed to me at inquest that there were two matters that had not yet been resolved.
i) At inquest, there was not a shared understanding among the clinicians within the trust about how such a situation should be approached.
The obstetricians were clear that, given her very high risk status, Phoenix’ mum needed to come in to hospital as soon as she showed the first signs of labour. And even if she had started to deliver, she could still only be treated effectively and Phoenix given the best chance of a good outcome in hospital.
However, some of the midwives felt strongly that, when Phoenix’ dad could see the baby’s leg emerge, they should have been allowed to go out to the home to give whatever assistance they could.
All the clinicians need have the same understanding of the correct protocol.
ii) A related point is that, before Phoenix was born, some of the midwives felt that their views of what should happen in the event of precipitous labour had not been taken seriously .
If they are to be effective in their role, and if necessary to understand why a protocol does fully reflect their feelings and views, the midwives’ ability to communicate with senior management needs to be enhanced .
If the team as a whole is to move forward in a way that provides the best possible care for women in labour and their babies, questions and differing opinions need to be in some way acknowledged and dealt with before the correct protocol can be embedded .
” 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 Assign a senior consultant obstetrician to the homebirth midwifery team and its monthly meetings to support case discussion, collaboration and sharing of learning.
Verbatim wording from the response “We would also like to reassure you that the homebirth midwifery team already meet monthly, and that meeting is attended by all the homebirth midwives unless they are attending a homebirth or on annual leave, in which case they can review the outcomes of the meeting on a shared drive. During this meeting they discuss any management issues or service updates, for example if there are any new guidelines. At this meeting, they also discuss all women booked in with them that are out of criteria for homebirth and review any new referrals that are out of criteria. This information is held and updated on a spreadsheet in a shared drive. The Matron for the Community Midwifery team attends this meeting, together with the Director of Midwifery, the Birth Options Midwife, and the named Midwife for Safeguarding.” Source location Response from Homerton Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the London Ambulance Service and North East London maternity system to formulate local standard operating procedures and guidance for imminent births and hospital-transfer refusals.
Verbatim wording from the response “As highlighted in the Prevention of Future Deaths Report, national maternity guidance is soon to be published which is to deal with the situation where a baby is ‘Born before Arrival’. The Trust has been working collaboratively with the LAS, and the North East London Local Maternity and Neonatal System (LMNS) to formulate a separate standard operating procedure and guidance for cases where the birth is imminent as there is currently no national guidance on this. Although this is being worked on at a local level, it is proposed that this will be part of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Guidance and shared nationally with the LMNS and national maternity units. This guidance is produced specifically for cases of birth imminent and advancing and cases where labouring women decline to be transferred to hospital, against the clinical advice of the paramedics.” Source location Response from Homerton Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind all Trust staff through the daily live communication that they can confidentially access the Freedom to Speak Up Guardian service.
Verbatim wording from the response “• The Trust has a Freedom to Speak Up Guardian, and six Freedom to Speak up Champions who are there to provide confidential advice and support to staff regarding concerns they may have, assist staff to raise concerns in the Trust and to make sure that staff receive feedback about the concerns that they have raised. The Trust Executive Team has a daily live communication on MS Teams for all Trust staff called 12 at 12. This is a live broadcast that takes place daily at midday for 12 minutes. Following this inquest, this communication reminded all Trust staff that they have access to the Freedom to Speak Up Guardian service if they would like to confidentially discuss any concerns.” Source location Response from Homerton Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Formulate escalation processes and criteria enabling midwives to raise concerns about birth plans for patients choosing birth outside guidance.
Verbatim wording from the response “In addition to this, our Birth Options Midwife and the community matron have formulated a process and criteria within times for midwives to escalate the out of guidance patients if there are any concerns regarding the current birth plan that is in place. This is again to ensure that there is a clear understanding regarding the birth plan.” Source location Response from Homerton Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint a new Director of Midwifery to lead ongoing meetings with the homebirth midwifery team and Chief Nurse.
Verbatim wording from the response “• Following this inquest, our Chief Nurse / Director of Clinical Governance has met with the homebirth midwifery team specifically to listen to how they feel and to see what support can be provided to them. The new Director of Midwifery started at the beginning of September and will lead further meetings with the homebirth midwifery team, together with the Chief Nurse monthly so that there is a forum to discuss any concerns that the midwives have. The next meeting is scheduled for 13th September 2023.” Source location Response from Homerton Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish monthly meetings between senior nursing leadership and the homebirth midwifery team to provide a forum for discussing staff concerns.
Verbatim wording from the response “• Following this inquest, our Chief Nurse / Director of Clinical Governance has met with the homebirth midwifery team specifically to listen to how they feel and to see what support can be provided to them. The new Director of Midwifery started at the beginning of September and will lead further meetings with the homebirth midwifery team, together with the Chief Nurse monthly so that there is a forum to discuss any concerns that the midwives have. The next meeting is scheduled for 13th September 2023.” Source location Response from Homerton Healthcare NHS Foundation Trust
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17 Dec 2021 Ziggy Dylan MITCHELL-STAGG · Prevention of Future Deaths report Inner North London
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Concerns raised 5 Lack of a local policy for use of centralised CTG monitoring View source Lack of standardised terminology for describing meconium View source Inadequate frequency of fresh eyes reviews for women in labour View source Failure of computer recording fields to reflect verbal descriptions of meconium View source Failure to document obstetric registrar assessments in the medical records View source See 2 more concerns
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AI-generated summary
Ziggy Dylan MITCHELL-STAGG · 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
Ziggy was born by emergency Caesarean section at Homerton University Hospital on 3 April 2021 in a very compromised state and died a few hours later. The concerns included inconsistent terminology for meconium, a lack of a medical-record entry by the attending obstetric registrar after 3.46am, no local policy on centralised CTG monitoring, and a trust policy providing for fresh-eyes reviews every two hours rather than the hourly national guidance.
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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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a local policy for use of centralised CTG monitoring
Wider context from the report “3. I was told that your trust does not have a local policy regarding the use of centralised CTG monitoring , and it seems that such a policy merits consideration.
” 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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised terminology for describing meconium
Wider context from the report “1. There was not standardisation of the terminology used by the midwives and obstetricians to describe the meconium found , and the information requested by the computer system to record this did not necessarily reflect the verbal descriptions. Sometimes grades I, II & III were used; sometimes significant & insignificant; sometimes thick or thin.
There was also inconsistency as to whether grade II was significant, and whether the term significant referred purely to the meconium noted, or to the meconium in the context of other features.
” 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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate frequency of fresh eyes reviews for women in labour
Wider context from the report “4. There is national guidance that there should be a fresh eyes review every hour for women in labour, but your trust policy indicates only every two hours. It seems that the trust policy merits reconsideration, either to amend it or to record why there is a departure from national guidance.
” 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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of computer recording fields to reflect verbal descriptions of meconium
Wider context from the report “1. There was not standardisation of the terminology used by the midwives and obstetricians to describe the meconium found, and the information requested by the computer system to record this did not necessarily reflect the verbal descriptions . Sometimes grades I, II & III were used; sometimes significant & insignificant; sometimes thick or thin.
There was also inconsistency as to whether grade II was significant, and whether the term significant referred purely to the meconium noted, or to the meconium in the context of other features.
” 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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document obstetric registrar assessments in the medical records
Wider context from the report “2. The obstetric registrar attending Ziggy’s mum did not make any note in the medical records after 3.46am, even retrospectively .
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and circulate maternity policies to replace Grade I–III meconium terminology with significant/insignificant terminology.
Verbatim wording from the response “b) As stated above, the Trust acknowledges that the grading of meconium is not up to date and is inconsistent. We therefore plan to hold a ‘Meconium Awareness Month’ where the following will happen:-” Source location 2021-0425-Homerton-University-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Liaise with neighbouring trusts to understand how they deliver hourly holistic fresh-eyes reviews.
Verbatim wording from the response “We agree that our Trust guidance needs revisiting and our first step in that process is to liaise with other neighbouring Trusts of similar acuity to learn from them and understand how they adhere to an hourly fresh eyes which not only assesses fetal well-being but provides a holistic view. We will then create our own action plan for implementation.” Source location 2021-0425-Homerton-University-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate the approved centralised CTG monitoring policy to staff and include it in daily handovers.
Verbatim wording from the response “A Policy has been drafted and has been signed off and approved. This will be circulated via an email to all staff and will be part of the daily handovers.” Source location 2021-0425-Homerton-University-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and approve a local policy for centralised CTG monitoring.
Verbatim wording from the response “A Policy has been drafted and has been signed off and approved. This will be circulated via an email to all staff and will be part of the daily handovers.” Source location 2021-0425-Homerton-University-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend quarterly documentation training delivered by the legal team to doctors, beginning with a session addressing this case.
Verbatim wording from the response “The obstetric registrar has been spoken to by her relevant manager and it has been agreed that she will attend an external course on documentation. Our in-house legal team provide training to the midwifery team on a monthly basis on the importance of documentation and this training will now be delivered to the doctors on a quarterly basis as well. The legal team will be delivering their first session on the 25th February 2022 where all doctors that cared for Ziggy’s mum will be in attendance and this case will be discussed.” Source location 2021-0425-Homerton-University-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use daily safety huddles and handovers to remind staff about the revised meconium terminology and related changes.
Verbatim wording from the response “• daily safety huddles and handovers will ensure that staff are reminded of this change and will be encouraged to take time to review all the changes;” Source location 2021-0425-Homerton-University-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a Trust action plan for implementing an hourly holistic fresh-eyes review after learning from neighbouring trusts.
Verbatim wording from the response “We agree that our Trust guidance needs revisiting and our first step in that process is to liaise with other neighbouring Trusts of similar acuity to learn from them and understand how they adhere to an hourly fresh eyes which not only assesses fetal well-being but provides a holistic view. We will then create our own action plan for implementation.” Source location 2021-0425-Homerton-University-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the approved meconium grading-system upgrade, including clinician prompts to record rationale and required escalation.
Verbatim wording from the response “a) Our computer system upgrade was already in place before the inquest, and one of the upgrades included updating the meconium grading from Grade I, II & III to the new system of Significant and Insignificant. The Trust has approved this change. A text box will now flash up once significant/insignificant is selected that will allow the clinician to enter the reason why they made that selection and when any onward action/escalation is needed. This change has been finalised and will be implemented by March 2022.” Source location 2021-0425-Homerton-University-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver specific staff training on identifying significant or insignificant meconium and using the new terminology in communication and records.
Verbatim wording from the response “b) As stated above, the Trust acknowledges that the grading of meconium is not up to date and is inconsistent. We therefore plan to hold a ‘Meconium Awareness Month’ where the following will happen:-” Source location 2021-0425-Homerton-University-Hospital_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A true hourly fresh-eyes review was not achievable during the previous trial, limiting immediate implementation of the national guidance.
Verbatim wording from the response “The trust realises that the hourly ‘fresh eyes’ review is embedded within national guidance and we want to strive to achieve this. The trust previously trialled this in 2019 however it was found that a true fresh eyes review was not achievable every hour.” Source location 2021-0425-Homerton-University-Hospital_Published
Open published response
13 Sep 2017 Bronwyn Ann WILLIAMS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Use of a slow, cumbersome and mishap-prone postal method for urgent referrals View source Delays in arranging maxillofacial appointments after referral View source
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AI-generated summary
Bronwyn Ann 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
Bronwyn Williams died on 23 May 2017 from a retropharyngeal abscess after attending hospital and a dentist with severe restricted mouth opening and malaise. The concerns included the use of postal referral for an urgent maxillofacial appointment and the failure to provide an appointment within two weeks; the appointment was ultimately scheduled nearly seven weeks after referral and Ms Williams died before being seen.
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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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Use of a slow, cumbersome and mishap-prone postal method for urgent referrals
Wider context from the report “1. I heard at inquest that the urgent referral from Kindandental to the Homerton was made not by logging on to a portal, or by email, or by fax, but by post . This seems unduly slow, cumbersome and prone to mishap .
” 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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in arranging maxillofacial appointments after referral
Wider context from the report “2. Following Ms Williams’ attendance at the dental surgery on 4 May, an appointment with the maxillofacial unit was made for 30 May, then cancelled by the Homerton on 23 May and re-fixed for 19 June . This date is nearly seven weeks post referral .
” Open source report
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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 cannot locally resolve the issues preventing dentists from using the electronic referral system, so the residual risk necessarily remains.
Verbatim wording from the response “I have attached the action plan developed in response to the PFD notice. We are one of the most advanced Trusts in London in relation to fully implementing electronic referrals via the e-RS system, known as Choose and Book, for GPs by April 2018. Unfortunately, although the system could in theory accept referrals from dentists, in practice they cannot use the system for reasons discussed in the action plan. We cannot fix these issues locally, and are therefore taking actions to mitigate the risk that necessarily remains.” Source location 2017-0215-Response-by-Homerton-University-Hospital-NHS
Open published response
10 Apr 2017 Christiana Pelle · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Lack of a clearly understood system for communicating concerns and relevant information between the Community District Nurses Team and a community patient’s care provider agency View source Lack of clear guidance for Community District Nursing team nurses on when to involve a community patient’s GP View source Absence of a clearly understood system for sharing relevant community patient information and escalating care-quality concerns between the Community District Nursing Team and partner agencies 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.
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AI-generated summary
Christiana Pelle · 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
Christiana Pelle developed a grade 4 sacral pressure ulcer while living at home under the care of community nursing and a planned care package. The ulcer became infected, and she later died in hospital after contracting pneumonia while receiving inpatient treatment. The principal concerns were unclear guidance about when nurses should involve a GP and inadequate systems for sharing information and escalating concerns between community nursing, other agencies, and the care provider.
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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clearly understood system for communicating concerns and relevant information between the Community District Nurses Team and a community patient’s care provider agency
Wider context from the report “(3) The lack of a clearly understood system for communicating concerns and/or other relevant information between the Community District Nurses Team and the care provider agency for a community 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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance for Community District Nursing team nurses on when to involve a community patient’s GP
Wider context from the report “(1) Lack of clear guidance and thus ongoing uncertainty on the part of the nurses in Homerton’s Community District Nursing team as to when they should seek the involvement of a community patient’s GP ;
” 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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a clearly understood system for sharing relevant community patient information and escalating care-quality concerns between the Community District Nursing Team and partner agencies
Wider context from the report “(2) An ongoing absence of any / any clearly understood system for sharing relevant information relating to a community patient and/or escalating concerns about the quality of the care they were receiving , between Homerton’s Community District Nursing Team and other partner agencies involved - in this instance the Community Mental Health Team from the East London NHS Foundation Trust’s City and Hackney Mental Health Care for Older People and the London Borough of Hackney’s Integrated Independence Team;
” Open source report
18 Mar 2016 Rubana PATHAN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Failure to disseminate information that toxins can suppress signs of local inflammation in patients at risk of sepsis 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
Rubana PATHAN · 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
Rubana Pathan was admitted to Homerton University Hospital and was diagnosed with toxic shock syndrome associated with a Staphylococcus aureus infection of an infected breast implant wound. A concern was raised that the absence of pus or localised redness may have contributed to the implant not being recognised as the cause of sepsis, because the responsible toxin can suppress signs of local inflammation.
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 Homerton Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate information that toxins can suppress signs of local inflammation in patients at risk of sepsis
Wider context from the report “Although Ms Pathan’s MENTOR breast implant was suspected as being the cause of her sepsis and was removed on the evening of Saturday, 7 November 2015, her surgeon told me at inquest that she still did not believe this to be the cause, because she found no pus or localised redness.
However, one of the treating microbiologists undertook a literature search after Ms Pathan’s death and discovered that the toxin found to be responsible for her illness can supress signs of local inflammation such as the production of pus.
Although this is a rare occurrence, it seems to me that the information could usefully be disseminated among those likely to be caring for patients who may be at risk of developing sepsis , both by the hospital and by the implant manufacturer.
” 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 Disseminate the literature search and the need for heightened suspicion of staphylococcal toxic shock syndrome to all Trust doctors.
Verbatim wording from the response “2. I have highlighted the need to have a high index of suspicion for sepsis associated with Staphylococcal Toxic Shock Syndrome, and shared ████████ detailed literature search, with all doctors in the Trust by email.” Source location 2016-0113-Response-by-Homerton-University-Hospital-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations