Recipient

James Paget University Hospital

First report 24 Dec 2015•Latest report 4 Aug 2020

Recipient record

Reports, concerns and published responses

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

Reports: 3
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

4 Aug2020
Norfolk
Concerns raised2
1. Failure to ensure discharge instructions are accessible and understood by patients
2. Failure to ascertain patients’ literacy
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

Pauline Russell · 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

Pauline Russell, a poorly controlled diabetic, was discharged from hospital after her insulin dose was increased, but she and her husband could not read the written discharge instructions. She subsequently received a higher incorrect insulin dose, became unresponsive in a hypoglycaemic coma, and died from aspiration pneumonia. The principal concern was that the hospital did not check patients’ literacy or provide discharge instructions in an accessible alternative format.

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 James Paget University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure discharge instructions are accessible and understood by patients
Wider context from the report
“No one checked whether Mrs Russell could read, her admission pack has a long section on communication but not once is the question asked can you read/write or something of that nature. Mrs Russell would have been given menus to select from and been expected to read other things whilst in hospital, but nobody checked that she could do this. On discharge no one checked that ████████ could read and understand the discharge summary. The inquest was 8 months after Mrs Russell’s death and when I asked the nurse who discharged her about his current practice around patients being asked about literacy his reply was “I’m thinking about it” so even a death had not altered his practice. The hospital has not introduced anything during this long period of time to ascertain if their patients can read/write. I appreciate that it can be embarrassing to ask the staff and patient, but it is vital that if people are being discharged home with written instructions, they can read them to check those instructions, or be shown in a different way what the instructions are, eg. a diagram, getting a relative to read them or a carer. I find it surprising that nothing has been done on the hospital’s own initiative in 8 months and I remain concerned that a similar incident may occur again. ”
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 James Paget University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to ascertain patients’ literacy
Wider context from the report
“No one checked whether Mrs Russell could read, her admission pack has a long section on communication but not once is the question asked can you read/write or something of that nature. Mrs Russell would have been given menus to select from and been expected to read other things whilst in hospital, but nobody checked that she could do this. On discharge no one checked that ████████ could read and understand the discharge summary. The inquest was 8 months after Mrs Russell’s death and when I asked the nurse who discharged her about his current practice around patients being asked about literacy his reply was “I’m thinking about it” so even a death had not altered his practice. The hospital has not introduced anything during this long period of time to ascertain if their patients can read/write. I appreciate that it can be embarrassing to ask the staff and patient, but it is vital that if people are being discharged home with written instructions, they can read them to check those instructions, or be shown in a different way what the instructions are, eg. a diagram, getting a relative to read them or a carer. I find it surprising that nothing has been done on the hospital’s own initiative in 8 months and I remain concerned that a similar incident may occur again. ”
Open source report
16 Jul2020
Norfolk
Concerns raised5
1. Failure to carry out a further vaginal examination after an hour before deciding how to proceed with delivery
2. Lack of recent emergency obstetrics training
3. Rotation of the baby’s head alone during obstructed delivery
1. Failure to appropriately interpret CTG readings and the full clinical picture before proceeding to delivery
2. Failure to accept consultant assistance during the procedure
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

Kobi David WRIGHT · 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

Kobi David WRIGHT was delivered on 3 March 2019 after unsuccessful forceps and caesarean delivery attempts and was declared dead after showing no signs of life. The concerns included conflicting accounts of cervical dilatation and the clinical reasoning for proceeding to delivery, failure to allow further progression before intervention, aspects of the forceps and caesarean procedures, and a lack of recent emergency obstetric training.

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 James Paget University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to carry out a further vaginal examination after an hour before deciding how to proceed with delivery
Wider context from the report
“5. Dr ████████ gave evidence that his arranging to take Kobi’s mother to theatre and prepare for delivery, and then carrying out a further vaginal examination at that time, would stand in for a later examination to see how matters were progressing. This was not regarded as good practice by the expert on the basis, it would be better to carry out a further examination after an hour, and then decide how to proceed with the delivery. ”
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 James Paget University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of recent emergency obstetrics training
Wider context from the report
“12. There was no evidence that Dr ████████ had undergone training in emergency obstetrics in the recent period prior 3 March 2019. Dr ████████ has undergone training since 3 March 2019 but at the instigation of North Devon District Hospital. ”
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 James Paget University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Rotation of the baby’s head alone during obstructed delivery
Wider context from the report
“7. Dr ████████ proceeded with a forceps delivery of the baby’s head. The body did not follow and the cervix “retracted” (which Dr ████████ had not encountered before. Nor had Mr ████████ the expert witness). Dr ████████ cut the cervix and rotated the head and tried unsuccessfully to deliver the shoulders through the incision. Mr ████████ expert said in evidence the baby’s head on its own should never be rotated due to the damage this can cause. ”
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 James Paget University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to appropriately interpret CTG readings and the full clinical picture before proceeding to delivery
Wider context from the report
“4. Further ████████ second statement 21.4.2020, refers to some consideration being given to variable decelerations and variabilities contained in the CTG trace when making his decision to proceed to delivery at that time. It was accepted by Dr ████████ Ms ████████ consultant and Mr ████████ expert, that the CTG readings were within normal range and would not be a reason to proceed to delivery at that time. Their evidence was it would be appropriate in light of the full clinical picture and the CTG readings to “wait and see” how matters progressed. ”
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 James Paget University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to accept consultant assistance during the procedure
Wider context from the report
“6. Dr ████████ did not accept the Consultant’s offer of assistance but regarded himself as fully competent to carry out the procedure. ”
Open source report
24 Dec2015
Norfolk
Concerns raised5
1. Failure to risk assess and make safe the physical environment before patient access
2. Failure of staff to understand required patient-observation practices
3. Lack of an agreed pathway for detained patients requiring assessment and treatment at A & E
1. Failure to record information gained from patient observations correctly
2. Failure of escort policy and planning to address inter-service patient transfers
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

CHRISTOPHER JONATHAN HIGGINS · 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

Christopher Jonathan Higgins died on 2 July 2013 after sustaining a head injury when he dived over railings while being taken outside for a cigarette at the Fermoy Unit. The report identified concerns about staff understanding of patient observations, patient transfers involving other services, risk assessment of the environment, and arrangements for detained patients requiring assessment and treatment at A&E.

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 James Paget University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to risk assess and make safe the physical environment before patient access
Wider context from the report
“(3) The safety of the environment where the incident took place, namely a disabled ramp with a railing along the edge and a concrete floor, had not been risk assessed prior to taking Mr Higgins outside for a cigarette. It is understood that since Mr Higgins' death the railing has been heightened. There was no evidence of a formal Risk Assessment having been undertaken since his death. Other ways of making the area safe are still under 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 James Paget University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of staff to understand required patient-observation practices
Wider context from the report
“(1) It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient. This was particularly evident with regard to Observations to be carried out on a "two members of staff to one patient" basis. Areas of confusion include how staff are to engage with a patient, how close they are required to be with regard to the patient, i.e. at arm's length or within eyesight and how to record the information gained from the Observation. ”
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 James Paget University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of an agreed pathway for detained patients requiring assessment and treatment at A & E
Wider context from the report
“(4) There is no agreement in place between the NSFT and the Acute Hospital as to the best way to deal with patients subject to detention under the Mental Health Act who require assessment and treatment at A & E, as a result of which Mr Higgins, was required to wait over 2 hours in a busy, public area, having already self-harmed and shown signs of paranoia. ”
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 James Paget University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to record information gained from patient observations correctly
Wider context from the report
“(1) It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient. This was particularly evident with regard to Observations to be carried out on a "two members of staff to one patient" basis. Areas of confusion include how staff are to engage with a patient, how close they are required to be with regard to the patient, i.e. at arm's length or within eyesight and how to record the information gained from the Observation. ”
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 James Paget University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of escort policy and planning to address inter-service patient transfers
Wider context from the report
“(2) The Escort Policy does not include information relating to the transfer of patients from one place to another (in this case from an Acute Hospital to the Fermoy Unit) when other services are involved, for instance the Police. In particular, Mr Higgins who had been acting in an unpredictable, and paranoid manner, was put into a cage at the rear of the Police van with three Police Officers, with no Mental Health staff to accompany him. The evidence did not reveal that this had been considered by the Mental Health staff previously attending to Mr Higgins; ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Failure to ensure discharge instructions are accessible and understood by patients

Failure to ascertain patients’ literacy

Concerns raised5

Failure to carry out a further vaginal examination after an hour before deciding how to proceed with delivery

Lack of recent emergency obstetrics training

Rotation of the baby’s head alone during obstructed delivery

Failure to appropriately interpret CTG readings and the full clinical picture before proceeding to delivery

Failure to accept consultant assistance during the procedure

Concerns raised5

Failure to risk assess and make safe the physical environment before patient access

Failure of staff to understand required patient-observation practices

Lack of an agreed pathway for detained patients requiring assessment and treatment at A & E

Failure to record information gained from patient observations correctly

Failure of escort policy and planning to address inter-service patient transfers