Concerns raised 1 Failure to use a single validated triage system universally in the Emergency Department 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.
×
AI-generated summary
Garth Pretorius · 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
Garth Pretorius became unwell after a medical procedure and was diagnosed with sepsis at Goole Urgent Treatment Centre. He was directed to Hull Royal Infirmary, where confusion over an impending emergency led to him and other patients being told to leave, delaying appropriate sepsis treatment by approximately 24 hours; this delay contributed to his death. The report also raises concern about two different triage systems being used simultaneously in the Emergency Department, with insufficient resources for universal adoption of the validated Manchester system.
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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use a single validated triage system universally in the Emergency Department
Wider context from the report “Evidence was heard from the Court’s independent expert that it is unacceptable for two different triage systems to be employed simultaneously in the Emergency Department of Hull Royal Infirmary . Professor Fletchager gave evidence that the Manchester system is validated and internationally accepted, but at material times, another system was used and continues to be used . Some practitioners use the Manchester system whilst others use a different system . Evidence was heard that the use of the Manchester system requires training and there do not appear to be sufficient resources still available for it to be adopted universally at Hull Royal Infirmary .
” Open source report
Concerns raised 3 Incomplete falls risk documentation View source Inaccurate falls risk assessments View source Failure to update falls risk assessments as required 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.
×
AI-generated summary
Raymond John MORAN · 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
Raymond John Moran, who had metastatic prostate cancer and other significant comorbidities, died on 24 December 2025 after an unwitnessed fall in hospital caused a right femur fracture. The report identifies concerns that his falls risk assessment was inaccurate, was not updated as required, and was incompletely documented.
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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete falls risk documentation
Wider context from the report “Evidence was heard at inquest that not only was the falls risk assessment inaccurate, but also, it was not updated as it should have been. In addition, the documentation was incomplete .
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate falls risk assessments
Wider context from the report “Evidence was heard at inquest that not only was the falls risk assessment inaccurate , but also, it was not updated as it should have been. In addition, the documentation was incomplete.
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update falls risk assessments as required
Wider context from the report “Evidence was heard at inquest that not only was the falls risk assessment inaccurate, but also, it was not updated as it should have been . In addition, the documentation was incomplete.
” Open source report
28 Jan 2026 Mrs Patricia Irene Walker · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1 Failure to maintain adequate staffing for TAG nursing care 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.
×
AI-generated summary
Mrs Patricia Irene Walker · 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
Patricia Irene Walker suffered a fractured neck of femur after a fall, followed by further falls in hospital, including a fall that resulted in an acute bilateral subdural haematoma. She was later discharged to a care home on a fast-track basis and died after poor nutritional intake, medication refusal and worsening confusion; the report raised concerns about suboptimal staffing on Ward 90 and increased falls risk.
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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate staffing for TAG nursing care
Wider context from the report “(1) Staffing was sub optimal and remain sub optimal on Ward 90 as recruitment is difficult which means that TAG nursing care is not always possible , and patients are at an increased risk of falls.
” Open source report
23 Dec 2024 David Christopher Peter Lodge · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 5 Failure to follow clinical recommendations for 30-minute observations View source Lack of internal investigation of serious incidents View source Failure to appropriately escalate NEWS2 scores above seven for specialist advice View source Failure to accurately assess pain in people unable to communicate with words View source Failure to carry out basic examinations for learning disabled adults at risk of pneumonia in the emergency department View source See 2 more concerns
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
David Christopher Peter Lodge · 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
David Christopher Peter Lodge, who had a learning disability, was found unwell beside his deceased father after lying for up to four days and died at Hull Royal Infirmary on 13 January 2022 from bilateral pneumonia. Concerns included inadequate pain assessment, no chest examination, failure to appropriately escalate high NEWS2 scores or transfer him to intensive care, and missed opportunities to learn from the death through a serious incident investigation.
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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow clinical recommendations for 30-minute observations
Wider context from the report “(3) NEWS2 scores above seven are not appropriately escalated for specialist advice. Clinical recommendations for 30 minute observations were not being followed. An independent expert, a Consultant in Intensive Care, gave evidence to the court that Mr Lodge should have been admitted to the Intensive Care Unit at Hull Royal Infirmary at which Mr Lodge would have undergone closer examinations on a lower patient to nurse ratio.
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of internal investigation of serious incidents
Wider context from the report “(4) Opportunities for learning from serious incidents are being lost. No internal investigation or other form of serious incident investigation was undertaken. The court heard evidence from independent experts who opined that it would be expected, following a death in these circumstances, for there to have been an internal review to consider improvements to include input from a specialist with a learning disability team.
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately escalate NEWS2 scores above seven for specialist advice
Wider context from the report “(3) NEWS2 scores above seven are not appropriately escalated for specialist advice. Clinical recommendations for 30 minute observations were not being followed. An independent expert, a Consultant in Intensive Care, gave evidence to the court that Mr Lodge should have been admitted to the Intensive Care Unit at Hull Royal Infirmary at which Mr Lodge would have undergone closer examinations on a lower patient to nurse ratio.
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately assess pain in people unable to communicate with words
Wider context from the report “(1) Pain is not accurately assessed in people who are unable to communicate with words. The court heard evidence that Mr Lodge at no point was provided pain relief, despite requests from the attending family member who was speaking on his behalf. An independent expert, a Consultant in Emergency Medicine, gave evidence that there was no evidence of reasonable adjustments in respect of assessing Mr Lodge’s pain to account for his baseline condition .
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out basic examinations for learning disabled adults at risk of pneumonia in the emergency department
Wider context from the report “(2) Basic examinations, including chest examinations, are not being carried out for learning disabled adults at risk of pneumonia in the emergency department. The treating physicians in evidence agreed that there should have been a high index of suspicion of pneumonia in Mr Lodge’s case and that it is one of the leading causes of death for people with learning disabilities. The court heard evidence that Mr Lodge did not have a chest examination carried out on him due to him not presenting any signs of respiratory distress. The independent expert gave evidence that a thorough examination should have been undertaken and that there was the opportunity to do so after the sedation medication was given.
” Open source report
24 Nov 2024 Colin Wiles · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 5 Failure to hold Vulnerable Adult Risk Management meetings when there are multifactorial concerns about comorbidities and self neglect View source Excessive ambulance patient handover waiting times at Hull Royal Infirmary View source Inability to hand over emergency ambulance patients into the emergency department at Hull Royal Infirmary View source Lack of criteria to reside for patients arriving in emergency ambulances View source Unclear advice to callers about calling emergency services back when concerns continue View source See 2 more concerns
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
Colin Wiles · 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
Colin Wiles, who lived alone and experienced self-neglect and hypothermia, was found collapsed at home and died at Hull Royal Infirmary on 27 March 2023. The principal concerns were that no Vulnerable Adult Risk Management meeting was held despite safeguarding concerns, and that excessive ambulance response and hospital handover times caused delays and lost ambulance capacity.
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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to hold Vulnerable Adult Risk Management meetings when there are multifactorial concerns about comorbidities and self neglect
Wider context from the report “(1) No Vulnerable Adult Risk Management meeting was held despite multifactorial concerns with Mr Wiles’ comorbidities and self neglect leading to poor living conditions and increased risk to his safety
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Excessive ambulance patient handover waiting times at Hull Royal Infirmary
Wider context from the report “(3) The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance time.
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inability to hand over emergency ambulance patients into the emergency department at Hull Royal Infirmary
Wider context from the report “(4) There appears to be an issue with no criteria to reside patients and the ability to hand over patients into ED in Hull Royal Infirmary who arrive in emergency ambulances .
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of criteria to reside for patients arriving in emergency ambulances
Wider context from the report “(4) There appears to be an issue with no criteria to reside patients and the ability to hand over patients into ED in Hull Royal Infirmary who arrive in emergency ambulances.
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear advice to callers about calling emergency services back when concerns continue
Wider context from the report “(2) It does not seem clear whether callers are advised to call the emergency services back if they continue to have concerns.
” Open source report
9 Mar 2024 Linda Heath · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 4 Insufficient inquiry into the parameters of care provided by private domiciliary carers View source Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information View source Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments View source Failure to make post-discharge referrals for patients needing district nursing care View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Linda Heath · 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
Linda Heath was discharged from hospital with a sacral sore, but the discharge information did not include a required district nursing referral and no referral was made. Her condition worsened, she was admitted to hospital, and she died on 31 March 2022 from sepsis caused by an infected sacral sore. The substantive concerns included inadequate discharge information, failure to arrange district nursing care, insufficient follow-up after discharge, and over-reliance on private domiciliary carers without sufficient enquiry into their remit.
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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient inquiry into the parameters of care provided by private domiciliary carers
Wider context from the report “(4) An over reliance upon private hygiene care packages with insufficient inquiry into the parameters of care provided by the private domiciliary carers .
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of immediate discharge summaries to include relevant and sufficient community treatment and nursing information
Wider context from the report “(1) The Immediate Discharge Summary did not include relevant or sufficient information about treatment in the community needs or a nursing summary .
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments
Wider context from the report “(3) No trigger appears to exist whereby GPs conduct follow up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their condition .
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make post-discharge referrals for patients needing district nursing care
Wider context from the report “(2) Despite the presence of a difficult sacral sore which would have benefitted from district nursing care, no referral was made post discharge by the GP surgery .
” 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 Discuss the appropriate level of information about community-nursing referrals for inclusion in medical discharge summaries.
Verbatim wording from the response “In relation to the immediate discharge summary this is a document completed by medical staff, and is intended to be a summary of the medical care. There are ongoing discussions about the level of information that should be included within the form, as it is important it does not become too lengthy, but the Trust is of the view that in order to prevent the problem that occurred in Linda’s case, the issue to be addressed is ensuring that appropriate referrals are made in the first place, by the Trust at the point of discharge. In Linda’s case if the discharge summary had noted the need for community nursing referral it is true that it is possible the GP could have followed this up, but in fairness it would not be the GP’s responsibility to do that. In Linda’s case she proactively sought input from her GP and their involvement was discussed at the Inquest.” Source location Response from HUTH
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 Remind staff to reassess and refer home-care packages for revision when patients’ hospital admission indicates changed care needs.
Verbatim wording from the response “The other issue of concern relevant to the Trust’s involvement (point 4) related to an over-reliance upon private hygiene care packages with insufficient enquiry into the parameters of care provided by the private domiciliary carers. At the point of discharge, patients who are in receipt of care packages at home need” Source location Response from HUTH
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 Finalize and roll out an electronic nursing discharge pro forma prompting community-nursing referral consideration and recording referral recipients.
Verbatim wording from the response “The Trust confirms that it has developed a pro forma to be utilised by nursing staff in relation to each and every discharge of an in-patient. This pro forma will be used when nurses are planning for a patient’s discharge, and it will identify and highlight a number of matters that need to be considered and addressed at the point of discharge. The pro forma is still being finalised, this work is expected to conclude within the next two weeks – because it is an electronic system, the Trust’s digital team has been involved in updating it. That said a number of words are already using the document in paper form but this will be rolled out across the Trust very shortly.” Source location Response from HUTH
Open published response
×
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 Concerns about points 2 and 3 relate to primary care rather than the Trust’s responsive responsibilities.
Verbatim wording from the response “Matters of concern at paragraph 5 of the Report are noted, and the Trust responds as it did at the Inquest in relation to points 1 and 4. Points 2 and 3 relate to primary care.” Source location Response from HUTH
Open published response
×
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 material risk arose from missed community nursing referrals at discharge, not insufficient information in the immediate discharge summary.
Verbatim wording from the response “Matters of concern at paragraph 5 of the Report are noted, and the Trust responds as it did at the Inquest in relation to points 1 and 4. Points 2 and 3 relate to primary care.” Source location Response from HUTH
Open published response
8 Feb 2024 Ethel Doreen Reed · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 5 Failure of the electronic patient record system to identify authors of changes to finalised discharge letters View source Risk of cross infection from misallocated patients’ personal effects View source Lack of continuity of nursing staff on winter-pressure wards View source Lack of visible ward leadership and a clear escalation pathway View source Paucity of personal care on the ward View source See 2 more concerns
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
Ethel Doreen Reed · 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
Ethel Doreen Reed fell at home, sustaining rib fractures that caused a pneumothorax and chest infection, and later developed pneumonia and Covid-19 while in hospital. She was discharged to a community rehabilitation centre while described as not medically fit for discharge and died there on 2 March 2023. The report raises concerns about staffing, continuity of care, personal care, leadership and escalation arrangements on a winter-pressure ward, as well as an electronic record system issue affecting identification of authors of discharge-letter changes.
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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the electronic patient record system to identify authors of changes to finalised discharge letters
Wider context from the report “(2) An issue with the Lorenzo electronic patient record keeping system has been identified in respect of the system not auto populating the identification of the author of any changes made in the immediate discharge letter (IDL) after it has been finalised . This could lead to miscommunication of critical issues and difficulties in establishing who made what decisions which could lead to delays in treatment in the next post discharge setting which in turn could lead to future deaths.
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of cross infection from misallocated patients’ personal effects
Wider context from the report “(1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward.
Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patients, their friends, or their families being able to have a clear escalation pathway to ventilate concerns. Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership. This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity of nursing staff on winter-pressure wards
Wider context from the report “(1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward .
Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patients, their friends, or their families being able to have a clear escalation pathway to ventilate concerns. Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership. This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of visible ward leadership and a clear escalation pathway
Wider context from the report “(1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward.
Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patients, their friends, or their families being able to have a clear escalation pathway to ventilate concerns . Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership . This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Paucity of personal care on the ward
Wider context from the report “(1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward.
Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patients, their friends, or their families being able to have a clear escalation pathway to ventilate concerns. Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership. This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing staff.
” Open source report
30 Jan 2024 Sylvia Linda WHITE · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 2 Failure to complete pre-discharge risk assessments View source Inadequacy of discharge summaries for ongoing care risk assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sylvia Linda WHITE · 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
Sylvia Linda WHITE, aged 92, was found pinned to the floor by an overturned wardrobe after an apparent fall or slip on 13 October 2023 and died in hospital on 28 October 2023 from a traumatic subdural haemorrhage. Concerns were raised that hospital discharge summaries did not adequately record her increased frailty and decreased mobility, resulting in insufficient information for carers’ ongoing risk assessments.
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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete pre-discharge risk assessments
Wider context from the report “3. Prior to this incident occurring Mrs White had been in hospital and discharged on 4th October 2023. A manager for the care home outlined that the paperwork provided to carers known as the “Discharge Summary” is often inadequate in providing suitable information. In this instance I was informed it did not provide any information on Mrs White’s increased frailty and decreased mobility. This means that information provided is inappropriate for ongoing risk assessments.
4. The manager did outline a particular form that they prefer, I make no comment regarding the format of the information required, merely the need for appropriate information to allow risk assessments to take place.
5. The manager stated that a social worker should be completing a risk assessment prior to discharge but this often does not happen . In many cases a doctor or another member of staff will complete a discharge summary. The information in these is often lacking to safeguard the welfare of the person concern with regard to their care needs. The manager stated they often have to alert safeguarding at the local authority of the deficit.
6. Bearing in mind the importance of a discharge summary in providing the foundation information for the ongoing safe care of patients as they leave the hospital environment, this is an issue where either a structured approach is required or training to those who are failing to complete them correctly 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of discharge summaries for ongoing care risk assessments
Wider context from the report “3. Prior to this incident occurring Mrs White had been in hospital and discharged on 4th October 2023. A manager for the care home outlined that the paperwork provided to carers known as the “Discharge Summary” is often inadequate in providing suitable information . In this instance I was informed it did not provide any information on Mrs White’s increased frailty and decreased mobility . This means that information provided is inappropriate for ongoing risk assessments .
4. The manager did outline a particular form that they prefer, I make no comment regarding the format of the information required, merely the need for appropriate information to allow risk assessments to take place.
5. The manager stated that a social worker should be completing a risk assessment prior to discharge but this often does not happen. In many cases a doctor or another member of staff will complete a discharge summary. The information in these is often lacking to safeguard the welfare of the person concern with regard to their care needs . The manager stated they often have to alert safeguarding at the local authority of the deficit.
6. Bearing in mind the importance of a discharge summary in providing the foundation information for the ongoing safe care of patients as they leave the hospital environment, this is an issue where either a structured approach is required or training to those who are failing to complete them correctly is required.
” 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 Relevant frailty and mobility information is provided through the TARF, which was appropriately completed and submitted for social care risk assessment.
Verbatim wording from the response “explained in the course of the inquest. Information regarding a patient’s frailty and mobility is detailed in a form known as a Trusted Assessor Referral Form (TARF) not the patient’s discharge summary, as suggested by the Care Manager. This form is sent from the hospital to the Local Authority, who risk assess the patient’s needs within the community. Trusted Assessor schemes are a national initiative designed to reduce delays when patients are ready for discharge from hospital. This approach allows adult social care providers to adopt and use assessments carried out while patients are still in hospital, promoting safe and timely discharges.” Source location Response from Hull University Teaching Hospitals
Open published response
17 Oct 2023 Tracey Elizabeth Rose · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 2 Failure to dispense prescribed dalteparin before discharge View source Failure to administer the final inpatient dose of dalteparin 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
Tracey Elizabeth Rose · 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
Tracey Elizabeth Rose suffered a right tibial plateau fracture and was discharged with a recommendation for six weeks of dalteparin, but missed up to three doses because of a dispensing issue. She was later admitted with a confirmed pulmonary embolism and died on 25 January 2023 after an embolectomy; the concern was that the missed anticoagulant doses may have significantly contributed to the pulmonary embolism.
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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to dispense prescribed dalteparin before discharge
Wider context from the report “(1) This woman was discharged home without her prescription of dalteparin being dispensed , also her last dose whilst in hospital may not have been given. Evidence was heard that missing up to three doses of this anticoagulant, in someone with increased risk factors for thromboembolic disease, may have significantly contributed to her developing a pulmonary embolism.
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer the final inpatient dose of dalteparin
Wider context from the report “(1) This woman was discharged home without her prescription of dalteparin being dispensed, also her last dose whilst in hospital may not have been given . Evidence was heard that missing up to three doses of this anticoagulant, in someone with increased risk factors for thromboembolic disease, may have significantly contributed to her developing a pulmonary embolism.
” Open source report
14 Nov 2019 Serena Jane Nicholas · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 4 Failure to ensure that the tertiary centre received information about prolonged fetal inactivity before planned C-section View source Lack of identified consultant oversight of diabetic and gynaecological aspects of high-risk pregnancy care View source Failure to provide continuity of antenatal care for a high-risk pregnancy View source Failure to recognise the need to advance a planned C-section through close monitoring of a high-risk pregnancy 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.
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AI-generated summary
Serena Jane Nicholas · 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
Serena Jane Nicholas was born by category 1 emergency Caesarean section on 29 August 2017 after fetal bradycardia and died shortly afterwards at Leeds General Infirmary from intrauterine hypoxia, with the pregnancy also involving a diabetic mother and a fetal heart abnormality. Concerns included disjointed management and a lack of identified consultants overseeing the high-risk pregnancy, as well as inadequate continuity of care and monitoring, meaning reduced fetal activity and the potential desirability of an earlier Caesarean section were not recognised.
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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that the tertiary centre received information about prolonged fetal inactivity before planned C-section
Wider context from the report “(2) The tertiary centre where the C-section (and the subsequent open heart surgery envisaged) were to take place, were not aware that the baby had been inactive for some days before the planned C-section (because the mother had not reported this and had not had contact with clinicians since the clinical appointment with a community midwife on 24/08/17 ). In consequence, a serious adverse development went unheeded until symptoms crossed on the eve of the C-section. In view of the history of the pregnancy continuity of care and close monitoring of a high risk pregnancy led to a situation in which the desirability of advancing the C-section by say, a week, was not recognised.
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of identified consultant oversight of diabetic and gynaecological aspects of high-risk pregnancy care
Wider context from the report “(1) The antenatal surveillance was largely carried out in Hull where the mother lived. She was seen by a variety of clinicians and at a late stage by a community midwife, despite the recognition that this was a pregnancy accompanied by clear risk factors. The absence of identified consultants responsible for the oversight of mother and baby’s care in relation to diabetic and gynaecological aspects resulted in disjointed management .
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuity of antenatal care for a high-risk pregnancy
Wider context from the report “(1) The antenatal surveillance was largely carried out in Hull where the mother lived. She was seen by a variety of clinicians and at a late stage by a community midwife , despite the recognition that this was a pregnancy accompanied by clear risk factors . The absence of identified consultants responsible for the oversight of mother and baby’s care in relation to diabetic and gynaecological aspects resulted in disjointed management.
” 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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the need to advance a planned C-section through close monitoring of a high-risk pregnancy
Wider context from the report “(2) The tertiary centre where the C-section (and the subsequent open heart surgery envisaged) were to take place, were not aware that the baby had been inactive for some days before the planned C-section (because the mother had not reported this and had not had contact with clinicians since the clinical appointment with a community midwife on 24/08/17). In consequence, a serious adverse development went unheeded until symptoms crossed on the eve of the C-section. In view of the history of the pregnancy continuity of care and close monitoring of a high risk pregnancy led to a situation in which the desirability of advancing the C-section by say, a week, was not recognised .
” Open source report
Concerns raised 1 Failure to account for the totality and synergistic effects of prescribed central nervous system and respiratory-depressant medication 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
Stuart Andrew WALLS · 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
Stuart Andrew WALLS was found dead in his room on 12 March 2017 after being last seen alive the previous morning. The inquest concluded that he died from drug poisoning caused by the combined effects of prescribed medication, with concern that multiple central-nervous-system medicines could have a synergistic effect on respiration even when taken at prescribed doses.
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 Hull University Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for the totality and synergistic effects of prescribed central nervous system and respiratory-depressant medication
Wider context from the report “Stuart died as a result of drug poisoning. However, there was no evidence of illicit drug use (other than cannabis which the Consultant Histopathologist confirmed had not played a part in the death). All prescribed drugs in his blood were within the therapeutic range.
The Consultant Histopathologist explained that the prescribed drugs had combined in a synergistic effect, acting together to poison Stuart.
My concern is that in the prescription of medication, particularly those that act on the central nervous system and affect respiration control, full account should be taken of the totality of drugs prescribed and their potential synergistic effect.
The reasons for my concern are:
Four prescription drugs namely Diazepam, Pregabalin, Amitriptyline and Promethazine were all found at a level consistent with therapeutic use. Each of these alone was at a level not expected to kill however each can exacerbate the effect of the other. I understood from the evidence that each of the drugs have a direct effect on the central nervous system. In particular a depressive effect on respiration. The Consultant Histopathologist confirmed this to be the case.
In addition to those prescribed drugs, methadone was also prescribed at 60 mg daily. That is well within normal prescription range. It was found at a level of 507ng/mL in blood. Methadone also has an effect on the central nervous system and is another respiratory depressor. The toxicology report said:
“...the deceased was prescribed 60mg of methadone daily. It has been reported that in 20 long-term opiate addicts who were administered a mean oral dose of 60mg methadone (range 10-225mg), the peak blood methadone concentrations ranged between 124-1255 ng/mL. It has been reported that in a study of 18 patients maintained on methadone 7.5 to 130 mg daily for at least 2 months, peak plasma concentrations of 69-698 ng/mL (pre-dose concentrations: 44-614 ng/mL) were achieved in 3 hours. The blood methadone level in the deceased was 507 ng/mL which may, therefore, reflect therapeutic use”.
It is of course, not known how much methadone Stuart had taken or when. However, properly taking the prescribed dose could still achieve the recorded level.
To put the amount of methadone into context, the toxicology evidence indicated a therapeutic range of 75 – 1100 ng/ml in blood; a toxic range of 200 – 2000 ng/ml and a fatal range of 400 – 2000 ng/mL. A level of tolerance builds with regular use.
Methadone is a potent opioid narcotic analgesic and would also have a synergistic effect together with the other four drugs mentioned above.
Therefore, even taking the properly prescribed medication as prescribed could have led to the situation that resulted in the death of Stuart WALLS. That is, drugs properly prescribed and properly taken could achieve a level, acting synergistically, that caused drug toxicity sufficient to cause death.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations