11 Nov 2025 Joan Elizabeth Talbot · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Failure to maintain continuity of care across admitting teams View source Failure to evaluate and refine record systems to support continuity of care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joan Elizabeth Talbot · 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
Joan Talbot had progressive complications from previous radiotherapy, including recurrent urinary tract infections, hydronephrosis and bloody diarrhoea. She was admitted to hospital on 14 August 2022, developed sepsis associated with a dislodged ureteric stent, and died on 24 August 2022 despite treatment. The principal concern was a lack of continuity of care across three earlier admissions, which meant the significance of her diarrhoea was not fully appreciated and delayed 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain continuity of care across admitting teams
Wider context from the report “1. Mrs Talbot had been admitted on 3 occasions when a history of diarrhoea, at times bloody, was reported before her final fourth admission. On each occasion she came under a different admitting team. There were gaps in continuity of care such that the significance of her history of diarrhoea was not fully appreciated resulting in delays in this presentation being investigated. Although the Trust has subsequently introduced a new record system that has the potential to assist with continuity of care, it has not asked itself how this system can be used most effectively to ensure continuity of care in this specific scenario, whether further refinements to the existing systems and processes may be 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to evaluate and refine record systems to support continuity of care
Wider context from the report “1. Mrs Talbot had been admitted on 3 occasions when a history of diarrhoea, at times bloody, was reported before her final fourth admission. On each occasion she came under a different admitting team. There were gaps in continuity of care such that the significance of her history of diarrhoea was not fully appreciated resulting in delays in this presentation being investigated. Although the Trust has subsequently introduced a new record system that has the potential to assist with continuity of care, it has not asked itself how this system can be used most effectively to ensure continuity of care in this specific scenario, whether further refinements to the existing systems and processes may be required.
” 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 Produce and use the Problem List Etiquette Guide to standardize problem-list and associated documentation practices.
Verbatim wording from the response “in October 2023, a number of quality improvement pieces of work have been undertaken to improve patient safety & quality, through an initial ‘stabilisation phase’ of urgent work, followed by an ‘optimisation phase’ of improving functionality across a number of domains. We are conscious that further improvements are required and we are not complacent with regard to pace and scope of this work. Improvements in medical notes documentation commenced over the last few months, in particular a ‘Problem List Etiquette Guide’ has been produced, which outlines expectations for the use of problem lists and associated documentation fields.” Source location Response from Kings College Hospital NHS Trust
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 Agree EPIC documentation metrics and audit standards to establish baseline quality and track improvement.
Verbatim wording from the response “Although the referenced problem list functionality was not yet deployed at the time of the incident (as the previous electronic patient record system was still in operation), the Trust acknowledges there is scope to enhance both EPIC’s documentation capabilities and the guidance provided to clinicians regarding its use. Therefore, in response to the concerns raised, the Trust has committed to establishing a cross-Trust EPIC Documentation Quality Group (‘DQG’). The DQG will be responsible for developing mechanisms to assess and monitor data quality, overseeing enhancements to documentation functionality, and leading targeted quality improvement initiatives. The drafting of the DQG’s terms of reference has specifically addressed the matters raised within the PFD, ensuring that the DQG’s work programme is both data-driven and aligned with identified risks.” Source location Response from Kings College Hospital NHS Trust
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 Oversee EPIC build changes, including navigators and note templates, to facilitate documentation quality improvement.
Verbatim wording from the response “Although the referenced problem list functionality was not yet deployed at the time of the incident (as the previous electronic patient record system was still in operation), the Trust acknowledges there is scope to enhance both EPIC’s documentation capabilities and the guidance provided to clinicians regarding its use. Therefore, in response to the concerns raised, the Trust has committed to establishing a cross-Trust EPIC Documentation Quality Group (‘DQG’). The DQG will be responsible for developing mechanisms to assess and monitor data quality, overseeing enhancements to documentation functionality, and leading targeted quality improvement initiatives. The drafting of the DQG’s terms of reference has specifically addressed the matters raised within the PFD, ensuring that the DQG’s work programme is both data-driven and aligned with identified risks.” Source location Response from Kings College Hospital NHS Trust
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 Establish a cross-Trust EPIC Documentation Quality Group to assess data quality, oversee documentation enhancements and lead targeted quality-improvement initiatives.
Verbatim wording from the response “Although the referenced problem list functionality was not yet deployed at the time of the incident (as the previous electronic patient record system was still in operation), the Trust acknowledges there is scope to enhance both EPIC’s documentation capabilities and the guidance provided to clinicians regarding its use. Therefore, in response to the concerns raised, the Trust has committed to establishing a cross-Trust EPIC Documentation Quality Group (‘DQG’). The DQG will be responsible for developing mechanisms to assess and monitor data quality, overseeing enhancements to documentation functionality, and leading targeted quality improvement initiatives. The drafting of the DQG’s terms of reference has specifically addressed the matters raised within the PFD, ensuring that the DQG’s work programme is both data-driven and aligned with identified risks.” Source location Response from Kings College Hospital NHS Trust
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 Design and oversee targeted documentation quality-improvement projects before wider rollout.
Verbatim wording from the response “Although the referenced problem list functionality was not yet deployed at the time of the incident (as the previous electronic patient record system was still in operation), the Trust acknowledges there is scope to enhance both EPIC’s documentation capabilities and the guidance provided to clinicians regarding its use. Therefore, in response to the concerns raised, the Trust has committed to establishing a cross-Trust EPIC Documentation Quality Group (‘DQG’). The DQG will be responsible for developing mechanisms to assess and monitor data quality, overseeing enhancements to documentation functionality, and leading targeted quality improvement initiatives. The drafting of the DQG’s terms of reference has specifically addressed the matters raised within the PFD, ensuring that the DQG’s work programme is both data-driven and aligned with identified risks.” Source location Response from Kings College Hospital NHS Trust
Open published response
28 Feb 2022 Martha Poppy MILLS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to provide an electronic paediatric early warning score and recording system View source Failure to maintain an effective formal relationship between paediatric hepatology and paediatric intensive care View source Failure to provide proactive paediatric intensive care outreach View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Martha Poppy MILLS · 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
Martha sustained a handlebar injury while cycling on a family holiday in Wales, was transferred to King’s College Hospital London, and died approximately one month later from refractory shock, sepsis, pancreatic transection and abdominal trauma. At King’s, she was not referred promptly to paediatric intensivists; concerns also included the paper-based paediatric early warning score system and stalled plans to improve coordination between paediatric hepatology and intensive care.
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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an electronic paediatric early warning score and recording system
Wider context from the report “1. I heard that the bedside paediatric early warning score (BPEWS) system at King’s is currently still paper based , unlike the adult system. It was put to me very forcefully by medical staff that, until the PEWS system moves to an electronic base as part of electronic recording of the paediatric records as a whole, monitoring and care of children may be sub optimal , with a higher risk of this sort of situation recurring.
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an effective formal relationship between paediatric hepatology and paediatric intensive care
Wider context from the report “2. The King’s serious incident investigation identified that Martha’s care fell down between the paediatric hepatologists and the paediatric intensivists . I heard evidence that it is the intention of King’s to improve the formal relationship between the hepatology and the paediatric intensive care departments , and to ensure that there is pro-active paediatric intensive care outreach.
However, the intended programme has stalled , I think partly because of the pandemic. It seems that there needs to be an impetus for this to be re-started and to gain sufficient momentum to operate smoothly in the future.
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide proactive paediatric intensive care outreach
Wider context from the report “2. The King’s serious incident investigation identified that Martha’s care fell down between the paediatric hepatologists and the paediatric intensivists. I heard evidence that it is the intention of King’s to improve the formal relationship between the hepatology and the paediatric intensive care departments, and to ensure that there is pro-active paediatric intensive care outreach .
However, the intended programme has stalled , I think partly because of the pandemic. It seems that there needs to be an impetus for this to be re-started and to gain sufficient momentum to operate smoothly in the future.
” 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 Develop and support training for rollout of electronic paediatric early warning scores, including the parental-concern trigger.
Verbatim wording from the response “Further training is being developed to support roll out of electronic PEWS, which include the parental concern trigger. The education team are part of the working group and will be supporting the roll out in June.” Source location 2022-0063-Response-from-Kings-College-Hospital_Published
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 Implement the fully integrated Epic electronic patient record with a customised paediatric early warning score.
Verbatim wording from the response “The Trust has very recently committed to the implementation of a fully integrated electronic patient record system (Epic) which will replace the vast majority of existing clinical IT systems in late 2023 and will provide a customised early warning score for paediatrics. However as an interim measure, with support from our in-house clinical IT support teams, we have now developed a way of capturing paediatric early warning scores on our existing electronic system. This will support clinical teams to capture all relevant observations, highlight patients at risk (to those at the bedside and those monitoring the wards overall), and ensure that the team can document what has been done to treat/escalate based on the score.” Source location 2022-0063-Response-from-Kings-College-Hospital_Published
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 Implement interim electronic capture of paediatric early warning scores on the existing clinical system.
Verbatim wording from the response “The Trust has very recently committed to the implementation of a fully integrated electronic patient record system (Epic) which will replace the vast majority of existing clinical IT systems in late 2023 and will provide a customised early warning score for paediatrics. However as an interim measure, with support from our in-house clinical IT support teams, we have now developed a way of capturing paediatric early warning scores on our existing electronic system. This will support clinical teams to capture all relevant observations, highlight patients at risk (to those at the bedside and those monitoring the wards overall), and ensure that the team can document what has been done to treat/escalate based on the score.” Source location 2022-0063-Response-from-Kings-College-Hospital_Published
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 Develop a bespoke organisational-development package to improve collaboration, communication and conflict management between hepatology and paediatric intensive care.
Verbatim wording from the response “• An organisational development expert has been identified to work alongside the Children’s Health Senior Leadership team to develop a bespoke package that will help to enhance effective clinical relationships between hepatology and the paediatric intensive care departments. The package consists of three stages which will help the teams to explore and build better relationships in relation to collaboration, communications and conflict.” Source location 2022-0063-Response-from-Kings-College-Hospital_Published
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 Submit a business case for a paediatric critical care outreach team for Investment Board consideration.
Verbatim wording from the response “Seek to fully fund a Paediatric Critical Care Outreach service to bring the paediatric service into alignment with adult critical services at KCH through submission of a business case | The business case for an outreach team has been written and submitted, and is due to be considered by the Trust’s Investment Board in May 2022.” Source location 2022-0063-Response-from-Kings-College-Hospital_Published
Open published response
8 May 2019 Mr Edward Hearn · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Lack of definitive cardiac-monitoring requirements in Carfilzomib prescribing information View source Failure of laboratory abnormal-result repeating, alerting and follow-up View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Edward Hearn · 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
Mr Edward Hearn died in hospital after a cardiac arrest, with the medical cause of death including sepsis, bronchopneumonia and multiple myeloma treated with chemotherapy. The report identified concerns that a high globulin result was not followed up, that he was discharged without a safe care plan to minimise fall risk during chemotherapy, and that cardiac monitoring requirements for Carfilzomib may not have been sufficiently definitive.
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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of definitive cardiac-monitoring requirements in Carfilzomib prescribing information
Wider context from the report “2. The expert pharmaceutical physician gave a recommendation that the need for cardiac monitoring was made more definitive in the drug prescribing information for Carfilzomib (and possibly others) , which was prescribed in the Cardamon Trial.
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of laboratory abnormal-result repeating, alerting and follow-up
Wider context from the report “1. The finding of a high globulin by a laboratory from a blood test in A&E was not followed up by either the laboratory or A&E department. It was not in College guidelines of tests which required urgent notification. It was indicative of a fatal disease, which was not diagnosed for approximately another 4 months. I accept the professional opinion of the haematologist that this was a system failure, which is not acknowledged by the Trust. The laboratory suggested an additional action to have an automated comment but that would still not deal with the problem of reports returning to physicians in secondary care. Evidence was heard that there is inconsistency in laboratory repeating and alerting of clinicians even between hospitals in the jurisdiction, and insufficient evidence of a safe system within the Trust .
” 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 Highlight to Emergency Department medical staff the importance of reviewing abnormal blood results and arranging appropriate follow-up.
Verbatim wording from the response “The Emergency Department (ED) treating doctor did not note the raised total protein and globulin found on the sample sent on 12 August 2017. This case is being used to highlight to ED medical staff the importance of noting abnormal blood test results and ensuring appropriate follow-up (outpatient or GP). Work is also ongoing to highlight to clinical teams the importance of reviewing test results on inpatients daily. The Trust uses a system called ‘Safety Net’ to circulate key learning themes for clinical teams to be aware of. A Safety Net is being prepared in relation to raised protein/globulin and the association with multiple myeloma. The ‘Screening Diagnostic Improvement Group’ looks at systems to ensure that test results are reviewed promptly to reduce clinical risk.” Source location Response from Kings College Hospital
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 Prepare a Safety Net communication on raised protein or globulin and its association with multiple myeloma.
Verbatim wording from the response “The Emergency Department (ED) treating doctor did not note the raised total protein and globulin found on the sample sent on 12 August 2017. This case is being used to highlight to ED medical staff the importance of noting abnormal blood test results and ensuring appropriate follow-up (outpatient or GP). Work is also ongoing to highlight to clinical teams the importance of reviewing test results on inpatients daily. The Trust uses a system called ‘Safety Net’ to circulate key learning themes for clinical teams to be aware of. A Safety Net is being prepared in relation to raised protein/globulin and the association with multiple myeloma. The ‘Screening Diagnostic Improvement Group’ looks at systems to ensure that test results are reviewed promptly to reduce clinical risk.” Source location Response from Kings College Hospital
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 Use the Screening Diagnostic Improvement Group to review systems for prompt test-result review and reduced clinical risk.
Verbatim wording from the response “The Emergency Department (ED) treating doctor did not note the raised total protein and globulin found on the sample sent on 12 August 2017. This case is being used to highlight to ED medical staff the importance of noting abnormal blood test results and ensuring appropriate follow-up (outpatient or GP). Work is also ongoing to highlight to clinical teams the importance of reviewing test results on inpatients daily. The Trust uses a system called ‘Safety Net’ to circulate key learning themes for clinical teams to be aware of. A Safety Net is being prepared in relation to raised protein/globulin and the association with multiple myeloma. The ‘Screening Diagnostic Improvement Group’ looks at systems to ensure that test results are reviewed promptly to reduce clinical risk.” Source location Response from Kings College Hospital
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 Critical-result telephone notification follows professional recommendations, which do not classify elevated total protein as requiring communication.
Verbatim wording from the response “The Trust follows the Royal College of Pathologists’ recommendations by telephoning out critical results to the requesting clinician or teams, 24 hours a day. Neither the recommendations in place at the time, ‘Out-of-hours reporting of laboratory results requiring urgent clinical action to primary care: Advice to pathologists and those that work in laboratory medicine, November 2010’, nor the recommendations superseding that document, ‘The communication of critical and unexpected pathology results, October 2017’, identify elevated total protein as a result that needs to be communicated to the requester as a critical limit.” Source location Response from Kings College Hospital
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 Trust disputes that every elevated globulin requires extensive investigation, citing multiple causes and poor clinical utility.
Verbatim wording from the response “The Trust recognises that a raised globulin (a constituent of total protein, which itself was elevated) as a component of liver function tests (LFTs) was not acted upon following an inpatient medical admission with pericarditis in August 2017, and that multiple myeloma was diagnosed in December 2017, when the Deceased presented at the Trust.” Source location Response from Kings College Hospital
Open published response
9 May 2014 Miss Abiola Dosunmu · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to communicate significant proteinuria to the ward View source Failure to diagnose a connective tissue disorder in the presence of exceptionally high ESR, elevated CK and proteinuria View source Failure to communicate the significance of persistently raised ESR and CK to the patient and family View source Failure to communicate discharge information and monitoring needs to primary care View source Failure to inform the consultant of the patient and imminent self-discharge before discharge View source Failure of the Serious Untoward Incident Investigation to consider concerns about clinical communication and consultant notification View source See 3 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
Miss Abiola Dosunmu · 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
Abiola Dosunmu developed abnormal blood tests, proteinuria and symptoms that were treated as cellulitis, before rapidly deteriorating and being found dead at home on 24 August 2012. The report identified concerns about failures to communicate the proteinuria and abnormal results, inadequate follow-up and monitoring, and a missed opportunity to diagnose and treat SLE earlier.
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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate significant proteinuria to the ward
Wider context from the report “(1) The 3+ proteinuria discovered in A&E was not communicated to the ward .
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to diagnose a connective tissue disorder in the presence of exceptionally high ESR, elevated CK and proteinuria
Wider context from the report “(4) Despite the exceptionally high ESR, elevated CK of which no cause was found and proteinuria, a diagnosis of cellulitis was preferred to that of a connective tissue disorder . The opportunity to treat her SLE was missed due to failure to diagnose the condition , whilst recognizing that diagnosis was hampered by her self discharge.
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the significance of persistently raised ESR and CK to the patient and family
Wider context from the report “(2) The Trust failed to communicate the significance of the persistently raised ESR and CK to the patient and family .
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate discharge information and monitoring needs to primary care
Wider context from the report “(3) The Trust failed to send the GP a discharge summary or communicate to the surgery the significance of the raised ESR and CK and the need for further monitoring .
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the consultant of the patient and imminent self-discharge before discharge
Wider context from the report “(5) Before discharge neither the patient nor the imminent self discharge were not known to the consultant , who would have wished to be informed and would have sought further investigations and communications.
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Serious Untoward Incident Investigation to consider concerns about clinical communication and consultant notification
Wider context from the report “(6) Concerns (2) (3) and (5) above were not considered by the Serious Untoward Incident Investigation by the Trust .
” Open source report
28 Apr 2014 Jennifer Tompkins · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Insufficient training for administration of IV medications View source Failure to document IV infusions stopped before full administration 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
Jennifer Tompkins · 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
Jennifer Tompkins, who was undergoing dialysis while awaiting a kidney transplant, suffered fatal allergic anaphylaxis after receiving an intravenous injection of Tazocin at Kings College Hospital on 6 July 2011. Concerns were raised that Tazocin may have been administered too quickly, indicating possible training issues, and that the early stopping of a vancomycin infusion was not recorded in drug administration records.
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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training for administration of IV medications
Wider context from the report “(1) The evidence at the inquest was that IV Tazocin should be given by slow IV injection. Mr Tindugen’s evidence was that he administered this drug over a period of 7 minutes. Even allowing for some uncertainty as to exact timings, the evidence (as set out in the timings given above) suggests that the drug was in fact administered too quickly . I am therefore concerned that there may be training issues relating to the administration of IV medications in this case .
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document IV infusions stopped before full administration
Wider context from the report “(2) Both Dr Kon and Mr Tindugen gave evidence that the IV vancomycin infusion was stopped early and before it had been fully administered. My concern is that both witnesses said that this fact would not be routinely documented in the drug administration records, and may not be recorded at all . There was no record in this case that the infusion was stopped early .
” Open source report
20 Aug 2013 Mohammed Mozammel Hussain CHAUDHURY · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Failure to follow pressure sore prevention guidance View source Deficiencies in pressure sore care planning and specialist referral View source Failure to establish safe staffing levels for unconscious patients requiring regular turning View source Failure to turn patients at the required frequency View source Insufficient nursing staffing capacity View source Inconsistent pressure sore risk scoring View source Failure of nursing care to prevent and manage pressure sores View source See 4 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
Mohammed Mozammel Hussain CHAUDHURY · 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
Mohammed Chaudhury suffered multiple injuries in a traffic collision and later developed five severe, septic pressure sores while in hospital. The report raised concerns about inadequate turning, incomplete care planning and tissue-viability referrals, inconsistent risk scoring, shortages in nursing staff, and uncertainty about whether staffing levels for unconscious patients requiring regular turning were safe.
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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow pressure sore prevention guidance
Wider context from the report “(2) Professional evidence confirmed that this was due to failure to turn regularly. 2 hourly turning was required, although this was not prescribed by tissue viability nurses or doctors. There were missing care plans, gaps in plans and delays in referral to TVN. Waterlow scoring was not consistent. Days were recorded when there were only 2, 3, 4, 5 or 6 turns per day. NICE guidance was not being followed . Some improvements in training and reporting have been reported.
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in pressure sore care planning and specialist referral
Wider context from the report “(2) Professional evidence confirmed that this was due to failure to turn regularly. 2 hourly turning was required, although this was not prescribed by tissue viability nurses or doctors. There were missing care plans, gaps in plans and delays in referral to TVN . Waterlow scoring was not consistent. Days were recorded when there were only 2, 3, 4, 5 or 6 turns per day. NICE guidance was not being followed. Some improvements in training and reporting have been reported.
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish safe staffing levels for unconscious patients requiring regular turning
Wider context from the report “(4) Although the ward has since been restructured and takes different cases, it was not possible to conclude that current staffing levels in the hospital for unconscious patients requiring regular turning were safe , as comparisons were difficult and the judgement required professional and managerial opinion.
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to turn patients at the required frequency
Wider context from the report “(2) Professional evidence confirmed that this was due to failure to turn regularly . 2 hourly turning was required, although this was not prescribed by tissue viability nurses or doctors. There were missing care plans, gaps in plans and delays in referral to TVN. Waterlow scoring was not consistent. Days were recorded when there were only 2, 3, 4, 5 or 6 turns per day . NICE guidance was not being followed. Some improvements in training and reporting have been reported.
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing staffing capacity
Wider context from the report “(3) Nursing rotas for the period were not available. Some days were reported as below establishment . (8 by day and 6 by night for 31 patients of which at least a ¼ were high dependency). Not all bank shifts were filled .
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent pressure sore risk scoring
Wider context from the report “(2) Professional evidence confirmed that this was due to failure to turn regularly. 2 hourly turning was required, although this was not prescribed by tissue viability nurses or doctors. There were missing care plans, gaps in plans and delays in referral to TVN. Waterlow scoring was not consistent . Days were recorded when there were only 2, 3, 4, 5 or 6 turns per day. NICE guidance was not being followed. Some improvements in training and reporting have been reported.
” 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 King'S College Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing care to prevent and manage pressure sores
Wider context from the report “(1) Infected pressure sores may have been a cause of death and they were unusual in extent and severity. Their development was prevented in ITU when he was most at risk and considerable improvement was achieved in the nursing home after discharge. Their development and deterioration related to nursing care on Murray Falconer ward in KCH between 27th September and 9th December.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations