Concerns raised 6 Delays in Trust investigation of serious care concerns View source Failure to raise incident reports for serious care concerns View source Failure of Trust investigations to identify critical care and treatment findings View source Lack of robust critical analysis to deliver timely patient-safety learning View source Lack of independent checks and challenge in single-surgeon emergency operating decisions View source Failure to conduct impartial investigation of clinical decision-making View source See 3 more concerns
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
Lindy Lyanne ASTON · 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
Lindy Lyanne Aston underwent a total gastrectomy for stomach cancer and later suffered a ruptured spleen, requiring emergency surgery. She was transferred from Kettering General Hospital to Leicester Royal Infirmary, where she underwent a splenectomy, remained very unwell and died on 18 October 2021. The principal concerns were the decision not to provide immediate surgery at Kettering and inadequacies in the Trust’s investigation and incident-reporting processes, which delayed learning about potential care failures.
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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 Kettering General Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in Trust investigation of serious care concerns
Wider context from the report “2) Trust investigations into Mrs Aston’s care – I am gravely concerned about the seeming inadequacies in the investigation and/or incident reporting processes at Kettering General Hospitals NHS Trust. The inquest was advised that a DATIX incident report was not raised in relation to Mrs Aston’s care or death.
I am concerned about the fact that Kettering General Hospitals NHS Trust did not look into the care provided to Mrs Aston until such time as the University Hospitals of Leicester NHS Trust contacted them about the inquest .
I am further concerned about the fact that when Kettering General Hospitals NHS Trust did look into the care provided to Mrs Aston they did so on the assumption that the clinical decision making had been appropriate, this makes the exploration of the care provided somewhat otiose.
The Trust’s exploration of the care provided to Mrs Aston failed to identify the fact that surgery should have been undertaken within an hour and the fact that, despite some of the assurances to the contrary, it would have been appropriate and possible to undertake that life-saving surgery at Kettering General Hospital.
The failure to properly investigate led to the wholly untenable situation where the Kettering General Hospital NHS Trust were alerted for the first time to the questionable clinical decision making and the potential errors in care at the inquest, which took place some 24 months after death (due to witness availability).
I am concerned that the lack of robust critical analysis and investigation of the clinical decision making and care provided to Mrs Aston at Kettering General Hospitals NHS Trust before her death has caused a delay to, and led to missed opportunities to learn lessons that are vital to patient safety.
My concerns relating to the inadequacy of the Trust’s exploration of the care provided to Mrs Aston and the risks related to that go far beyond just the care provided by the Surgical Team at Kettering General Hospital NHS Trust. The risks have the ability to prevent learning, therefore negatively impact upon patient safety, across the entire Trust.
” 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 Kettering General Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to raise incident reports for serious care concerns
Wider context from the report “2) Trust investigations into Mrs Aston’s care – I am gravely concerned about the seeming inadequacies in the investigation and/or incident reporting processes at Kettering General Hospitals NHS Trust. The inquest was advised that a DATIX incident report was not raised in relation to Mrs Aston’s care or death .
I am concerned about the fact that Kettering General Hospitals NHS Trust did not look into the care provided to Mrs Aston until such time as the University Hospitals of Leicester NHS Trust contacted them about the inquest.
I am further concerned about the fact that when Kettering General Hospitals NHS Trust did look into the care provided to Mrs Aston they did so on the assumption that the clinical decision making had been appropriate, this makes the exploration of the care provided somewhat otiose.
The Trust’s exploration of the care provided to Mrs Aston failed to identify the fact that surgery should have been undertaken within an hour and the fact that, despite some of the assurances to the contrary, it would have been appropriate and possible to undertake that life-saving surgery at Kettering General Hospital.
The failure to properly investigate led to the wholly untenable situation where the Kettering General Hospital NHS Trust were alerted for the first time to the questionable clinical decision making and the potential errors in care at the inquest, which took place some 24 months after death (due to witness availability).
I am concerned that the lack of robust critical analysis and investigation of the clinical decision making and care provided to Mrs Aston at Kettering General Hospitals NHS Trust before her death has caused a delay to, and led to missed opportunities to learn lessons that are vital to patient safety.
My concerns relating to the inadequacy of the Trust’s exploration of the care provided to Mrs Aston and the risks related to that go far beyond just the care provided by the Surgical Team at Kettering General Hospital NHS Trust. The risks have the ability to prevent learning, therefore negatively impact upon patient safety, across the entire Trust.
” 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 Kettering General Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Trust investigations to identify critical care and treatment findings
Wider context from the report “2) Trust investigations into Mrs Aston’s care – I am gravely concerned about the seeming inadequacies in the investigation and/or incident reporting processes at Kettering General Hospitals NHS Trust. The inquest was advised that a DATIX incident report was not raised in relation to Mrs Aston’s care or death.
I am concerned about the fact that Kettering General Hospitals NHS Trust did not look into the care provided to Mrs Aston until such time as the University Hospitals of Leicester NHS Trust contacted them about the inquest.
I am further concerned about the fact that when Kettering General Hospitals NHS Trust did look into the care provided to Mrs Aston they did so on the assumption that the clinical decision making had been appropriate, this makes the exploration of the care provided somewhat otiose.
The Trust’s exploration of the care provided to Mrs Aston failed to identify the fact that surgery should have been undertaken within an hour and the fact that, despite some of the assurances to the contrary, it would have been appropriate and possible to undertake that life-saving surgery at Kettering General Hospital .
The failure to properly investigate led to the wholly untenable situation where the Kettering General Hospital NHS Trust were alerted for the first time to the questionable clinical decision making and the potential errors in care at the inquest, which took place some 24 months after death (due to witness availability).
I am concerned that the lack of robust critical analysis and investigation of the clinical decision making and care provided to Mrs Aston at Kettering General Hospitals NHS Trust before her death has caused a delay to, and led to missed opportunities to learn lessons that are vital to patient safety.
My concerns relating to the inadequacy of the Trust’s exploration of the care provided to Mrs Aston and the risks related to that go far beyond just the care provided by the Surgical Team at Kettering General Hospital NHS Trust. The risks have the ability to prevent learning, therefore negatively impact upon patient safety, across the entire Trust.
” 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 Kettering General Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of robust critical analysis to deliver timely patient-safety learning
Wider context from the report “2) Trust investigations into Mrs Aston’s care – I am gravely concerned about the seeming inadequacies in the investigation and/or incident reporting processes at Kettering General Hospitals NHS Trust. The inquest was advised that a DATIX incident report was not raised in relation to Mrs Aston’s care or death.
I am concerned about the fact that Kettering General Hospitals NHS Trust did not look into the care provided to Mrs Aston until such time as the University Hospitals of Leicester NHS Trust contacted them about the inquest.
I am further concerned about the fact that when Kettering General Hospitals NHS Trust did look into the care provided to Mrs Aston they did so on the assumption that the clinical decision making had been appropriate, this makes the exploration of the care provided somewhat otiose.
The Trust’s exploration of the care provided to Mrs Aston failed to identify the fact that surgery should have been undertaken within an hour and the fact that, despite some of the assurances to the contrary, it would have been appropriate and possible to undertake that life-saving surgery at Kettering General Hospital.
The failure to properly investigate led to the wholly untenable situation where the Kettering General Hospital NHS Trust were alerted for the first time to the questionable clinical decision making and the potential errors in care at the inquest, which took place some 24 months after death (due to witness availability).
I am concerned that the lack of robust critical analysis and investigation of the clinical decision making and care provided to Mrs Aston at Kettering General Hospitals NHS Trust before her death has caused a delay to, and led to missed opportunities to learn lessons that are vital to patient safety .
My concerns relating to the inadequacy of the Trust’s exploration of the care provided to Mrs Aston and the risks related to that go far beyond just the care provided by the Surgical Team at Kettering General Hospital NHS Trust. The risks have the ability to prevent learning, therefore negatively impact upon patient safety, across the entire Trust.
” 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 Kettering General Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of independent checks and challenge in single-surgeon emergency operating decisions
Wider context from the report “1) Surgical decision making – I am concerned about the fact that the decision about whether to operate on a patient or not lies with one single surgeon with seemingly no checks or balances around their decision making . It concerns me that all of the witnesses at the inquest agreed that Mrs Aston needed immediate life-saving surgery when she presented to Kettering General Hospital yet there was no challenge to the decisions made by the on-call surgeon not to operate .
” 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 Kettering General Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct impartial investigation of clinical decision-making
Wider context from the report “2) Trust investigations into Mrs Aston’s care – I am gravely concerned about the seeming inadequacies in the investigation and/or incident reporting processes at Kettering General Hospitals NHS Trust. The inquest was advised that a DATIX incident report was not raised in relation to Mrs Aston’s care or death.
I am concerned about the fact that Kettering General Hospitals NHS Trust did not look into the care provided to Mrs Aston until such time as the University Hospitals of Leicester NHS Trust contacted them about the inquest.
I am further concerned about the fact that when Kettering General Hospitals NHS Trust did look into the care provided to Mrs Aston they did so on the assumption that the clinical decision making had been appropriate , this makes the exploration of the care provided somewhat otiose.
The Trust’s exploration of the care provided to Mrs Aston failed to identify the fact that surgery should have been undertaken within an hour and the fact that, despite some of the assurances to the contrary, it would have been appropriate and possible to undertake that life-saving surgery at Kettering General Hospital.
The failure to properly investigate led to the wholly untenable situation where the Kettering General Hospital NHS Trust were alerted for the first time to the questionable clinical decision making and the potential errors in care at the inquest, which took place some 24 months after death (due to witness availability).
I am concerned that the lack of robust critical analysis and investigation of the clinical decision making and care provided to Mrs Aston at Kettering General Hospitals NHS Trust before her death has caused a delay to, and led to missed opportunities to learn lessons that are vital to patient safety.
My concerns relating to the inadequacy of the Trust’s exploration of the care provided to Mrs Aston and the risks related to that go far beyond just the care provided by the Surgical Team at Kettering General Hospital NHS Trust. The risks have the ability to prevent learning, therefore negatively impact upon patient safety, across the entire Trust.
” 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 Rewrite and implement the mortality-review policy for externally identified concerns, including formal notification, committee oversight, Structured Judgement Review, escalation and multidisciplinary review.
Verbatim wording from the response “We have reviewed the Trusts Medical Examiner and Mortality Review and Learning from Adult Inpatient Deaths Policy (Ref GOV01). The policy is very clear in relation to the Structured Judgement Review (SJR) outcomes. Section 8 of this policy refers to the processes to be followed when the outcome of an SJR is deemed very poor or avoidable with a score of 1-3. More specifically, section 8.5 refers to the process to be followed when an SJR is referred from an external organisation, for example when a patient was treated at KGH, then transferred to another hospital, and dies. This section states that these referred concerns will go through an SJR process and governance process for mortality reviews.” Source location Response from Kettering General Hospital NHS Foundation Trust
Open published response
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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 Introduce and roll out Stop the Line across the Trust, incorporating concerns into Datix reporting and daily team huddles.
Verbatim wording from the response “Whilst the responsibility for decision making regarding a patient’s care rests with the named consultant, all members of the clinical team are encouraged to speak up if they have any safety concerns in real time. One such example is “Stop the Line” which was been introduced into the treatment centre in May 2023 and which has been rolled out” Source location Response from Kettering General Hospital NHS Foundation Trust
Open published response
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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 Continue reviewing existing routes for raising concerns and challenging clinical decisions to reinforce the Trust’s safety culture.
Verbatim wording from the response “The Trust has a well-developed Freedom to Speak Up process with an active Freedom to Speak Up Guardian and several specialty-based Freedom to Speak Up ambassadors. Freedom to Speak Up enables staff to report any concerns if they did not feel able to do so in the moment and can be done anonymously, whereas Stop the Line is aimed at empowering staff to speak up ‘in the moment’ if there are any concerns. The Trust does have safety and raising concerns as a central part of its culture work and will continue to review existing paths to reinforce raising concerns and challenging a decision.” Source location Response from Kettering General Hospital NHS Foundation Trust
Open published response
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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 round table panel concluded that no further action was necessary regarding the concerns about the patient's care.
Verbatim wording from the response “A round table panel was convened 23/2/2022, following notification from the Coroner of Mrs Aston’s death. The panel made the decision that no further action need be taken.” Source location Response from Kettering General Hospital NHS Foundation Trust
Open published response
28 Jan 2020 Susan Sterland · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Failure to provide senior doctor review for deteriorating patients 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
Susan Sterland · 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
Susan Sterland was brought to Kettering General Hospital on 29 December 2018 with an intestinal obstruction that was not diagnosed, and was admitted after being diagnosed with constipation. Her condition deteriorated, care was not escalated, and she collapsed and died early on 31 December 2018. The principal concern was that she was not seen by a senior doctor despite deterioration and remaining in hospital for about 40 hours; the report states that earlier senior review might have led to investigation and earlier diagnosis.
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 Kettering General Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide senior doctor review for deteriorating patients
Wider context from the report “This was obviously a very busy time at the hospital. However, Ms Sterland was in the hospital for some 40 hours, she was not getting better, there were signs that she was deteriorating during the late morning and afternoon of 30 December , there was a plan to admit her to a ward but there were no beds available. My concern is that in this situation she was not seen by a senior doctor . If Ms Sterland had been seen by a senior doctor the evidence was that she would have had further investigation which would have led to earlier diagnosis of the obstruction and may have altered the outcome.
The evidence at the inquest suggested that there are some categories of patients in the emergency department for whom a senior review is mandatory. It may be that the Trust would wish to consider whether the circumstances of this case suggest that there are other situations in which a senior review should be required.
” 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 Increase daily senior decision-making capacity by adding middle-grade shifts and a second consultant shift in the Emergency Department.
Verbatim wording from the response “The Department medical rota has been changed to increase the number of senior decision makers present within the department on each day. As a result the number of middle-grade shifts has been increased from 9 to 11 shifts, daily. In addition, the number of consultants in the department has been increased by adding a second consultant shift from 15:00 to 22.00 and we are aiming to have 2 consultants in ED from 08:00 to 22.00. This will allow a timely senior review of patients and will provide consultant ward rounds for EDU.” Source location 2020-0062-Response-from-Kettering-General-Hospital_Redacted
Open published response
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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 Ratify and implement an updated ED standard operating policy defining responsibility for each patient and escalation arrangements.
Verbatim wording from the response “1. A revision to the Standard Operating Practice to set out who is responsible for reviewing patients:” Source location 2020-0062-Response-from-Kettering-General-Hospital_Redacted
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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 Create a new EDU operating policy specifying consultant ward-round responsibility, patient ownership and risks identified in the report before recommissioning.
Verbatim wording from the response “The EDU was decommissioned in March 2020 in response to Covid 19. The area where EDU was located is currently being used as ED Major cubicles which are part of the ED footprint.” Source location 2020-0062-Response-from-Kettering-General-Hospital_Redacted
Open published response
12 Oct 2015 Mrs Withers · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 5 Inadequate policy for calling back a lifeline or third party when the patient cannot receive calls View source Delays in ambulance staff handover to hospital View source Inadequate policy or procedure for saving essential patient medical history in ambulance service electronic data systems View source Inadequate policy on staff abstraction tolerance and levels View source Inadequate policy for obtaining patient medical history during the first 999 call 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.
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AI-generated summary
Mrs Withers · 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
Mrs Withers, aged 77, suffered a fall at home causing a fracture, significant haemorrhage and cardiac arrest. She died after a 2 hour 50 minute delay before paramedics arrived. The concerns included procedures for obtaining and retaining medical history, calling back a lifeline or third party, staffing levels, and ambulance handover times at hospital.
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 Kettering General Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate policy for calling back a lifeline or third party when the patient cannot receive calls
Wider context from the report “2) The policy in relation to calling back a life line/third party where the patient is unable to receive calls .
” 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 Kettering General Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance staff handover to hospital
Wider context from the report “5) The policy and protocol in relation to hand over times between East Midlands Service paramedics and Kettering General Hospital Accident and Emergency staff (the concern being the apparent loss of time by ambulance staff during the handover of patient to 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 Kettering General Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate policy or procedure for saving essential patient medical history in ambulance service electronic data systems
Wider context from the report “3) The policy/procedure in relation to saving essential patient medical history in the ambulance service electronic data systems .
” 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 Kettering General Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate policy on staff abstraction tolerance and levels
Wider context from the report “4) The policy in relation to staff abstraction tolerance and levels .
” 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 Kettering General Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate policy for obtaining patient medical history during the first 999 call
Wider context from the report “1) The policy in relation to obtaining a patient’s medical history during the first 999 call, reporting an incident .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations