Kettering General Hospital

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First report 16 Jun 2017•Latest report 14 Jan 2022

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

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

Concerns and recipient responses

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

14 Jan2022
Northamptonshire
Concerns raised6
1. Failure to accept recommendations to carry and administer buccal midazolam when necessary
2. Failure to ask parents whether the child had vomited
3. Lack of paramedic training in the use of buccal midazolam
1. Lack of evidence of paramedic training following an independent Serious Incident Report and agreed recommendations
2. Failure to attempt alternative oxygenation
3. Failure to attempt suction
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Alfie Stone · 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

Alfie Stone, aged 12, died after prolonged seizures, status epilepticus, hypoxia and multiple organ failure following admission to hospital. Concerns included paramedics’ lack of training in buccal midazolam, inadequate oxygenation, no suction attempt, and insufficient evidence of training following an earlier Serious Incident Report.

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; that does not assign responsibility.
PFD Monitor interpretation
Failure to accept recommendations to carry and administer buccal midazolam when necessary
Wider context from the report
“(5) East Midlands Ambulance Service were not accepting the recommendations 3 within the report to carry and administer Buccal Midazolam when necessary. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to ask parents whether the child had vomited
Wider context from the report
“(3) No suction attempted and the question was not asked of the parents as to whether the child had vomited. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Lack of paramedic training in the use of buccal midazolam
Wider context from the report
“(1) Apparent lack of training of paramedics in the use of Buccal Midazolam ”
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; that does not assign responsibility.
PFD Monitor interpretation
Lack of evidence of paramedic training following an independent Serious Incident Report and agreed recommendations
Wider context from the report
“(4) No evidence of training to the paramedics who attended and gave evidence following an independent Serious Incident Report and its agreed recommendations ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to attempt alternative oxygenation
Wider context from the report
“(2) No other form of oxygenation attempted such as bagging or the child being taken earlier to the ambulance to secure and deliver oxygen ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to attempt suction
Wider context from the report
“(3) No suction attempted and the question was not asked of the parents as to whether the child had vomited. ”
Open source report
14 May2018
Northamptonshire
Concerns raised8
1. Lack of a mechanism to ensure safe delivery and discharge of Falls Prevention Service input
2. Failure of the Falls Prevention Service to proactively follow up required input
3. Failure to transmit and resubmit completed falls action plans through the required process
1. Failure to use appropriate falls referral thresholds
2. Unavailability of required falls prevention equipment
3. Failure to consider and action falls risk action plan advice
4. Failure to make new falls prevention referrals after further falls
5. Failure to identify falls risks during pre-assessment
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Gladys Kathleen Rich · 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

Gladys Kathleen Rich suffered repeated falls after moving into Avenue House Nursing and Care Home, culminating in a fall on 28 December 2016 that caused traumatic subdural and subarachnoid haemorrhages and a skull fracture. She died on 3 March 2017; the medical cause of death included chest infection, intracranial haemorrhage and a fall, with rectal cancer and liver metastases also recorded. The principal concerns related to failures to identify and manage her falls risk, ineffective referral and follow-up by the care home and Falls Prevention Service, inadequate resources and equipment, and the absence of an effective system to ensure required falls-prevention input was delivered.

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; that does not assign responsibility.
PFD Monitor interpretation
Lack of a mechanism to ensure safe delivery and discharge of Falls Prevention Service input
Wider context from the report
“3. There does not seem to be any mechanism for ensuring that Falls Prevention Service input is in fact delivered when it is required and that a patient is only ever discharged or that it is clear that the underlying symptoms causing the falls are resolved or that measures have been put in place to mitigate the falls risk. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure of the Falls Prevention Service to proactively follow up required input
Wider context from the report
“2. In relation to the Falls Prevention Service. a) Despite Mrs Rich having been referred to the Falls Prevention Service by her GP and the service being notified of a fall related hospitalisation in August 2016, the onus was placed on the patient and her family to make a further appointment. In the absence of any further contact, the service assumes that their input is no longer required. As is clear in the case of Mrs Rich, the prevention service was very much still required. Again, when the service was contacted in November 2016 the failure to receive a form or a response to the subsequent letter again led to an automatic assumption that input was no longer required despite the fact that this was the second referral to have been made in relation to Mrs Rich. It was explained in evidence that the reason the service cannot be more proactive is because they are inadequately resourced. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to transmit and resubmit completed falls action plans through the required process
Wider context from the report
“c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to use appropriate falls referral thresholds
Wider context from the report
“b) The policy of waiting for 3 falls before making a referral seems to be arbitrary and also at odds with the Fall Prevention Service requirement of 1 fall within a 12 month period before a referral will be accepted. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of required falls prevention equipment
Wider context from the report
“d) The care home may not have some of the equipment that they require for patients such as Mrs Rich e.g. a bed sensor mat. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider and action falls risk action plan advice
Wider context from the report
“c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to make new falls prevention referrals after further falls
Wider context from the report
“c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to identify falls risks during pre-assessment
Wider context from the report
“a) Failure to identify Mrs Rich as a falls risk during a pre-assessment process, despite the fact that she had sustained a fall requiring hospitalisation 9 months before. The pre-assessment check may not therefore be sufficiently robust. ”
Open source report
16 Jun2017
Northamptonshire
Concerns raised2
1. Failure to seek attendance by the attending spinal surgeon for postoperative instability
2. Failure to consider internal haemorrhage as a cause of instability after elective spinal surgery
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mrs Macrae · 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 Macrae was admitted for elective lumbar spinal surgery and experienced intermittent drops in blood pressure during recovery. The report raises concern that internal haemorrhage was not considered as a possible cause of her instability and that this rare but recognised complication should be understood after similar surgery.

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; that does not assign responsibility.
PFD Monitor interpretation
Failure to seek attendance by the attending spinal surgeon for postoperative instability
Wider context from the report
“1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend. Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability. 2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider internal haemorrhage as a cause of instability after elective spinal surgery
Wider context from the report
“1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend. Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability. 2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery. ”
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 raised6

Failure to accept recommendations to carry and administer buccal midazolam when necessary

Failure to ask parents whether the child had vomited

Lack of paramedic training in the use of buccal midazolam

Lack of evidence of paramedic training following an independent Serious Incident Report and agreed recommendations

Failure to attempt alternative oxygenation

Failure to attempt suction

Concerns raised8

Lack of a mechanism to ensure safe delivery and discharge of Falls Prevention Service input

Failure of the Falls Prevention Service to proactively follow up required input

Failure to transmit and resubmit completed falls action plans through the required process

Failure to use appropriate falls referral thresholds

Unavailability of required falls prevention equipment

Failure to consider and action falls risk action plan advice

Failure to make new falls prevention referrals after further falls

Failure to identify falls risks during pre-assessment

Concerns raised2

Failure to seek attendance by the attending spinal surgeon for postoperative instability

Failure to consider internal haemorrhage as a cause of instability after elective spinal surgery