Recipient

King's College Hospital

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First report 2 Oct 2015•Latest report 29 Jul 2022

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
7

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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 King's College Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner South London

    AI-generated summary

    Mr Locksley Burton · 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 Locksley Burton, an 80-year-old disabled right leg amputee with dementia and other conditions, died in hospital on 24 April 2020 from mixed natural causes including systemic sepsis, Covid-19 pneumonia and osteomyelitis of the left heel. Concerns included inadequate wound inspections and dressing changes after diabetic foot clinic attendance was reduced, insufficient communication and care planning, and no demonstrated process for managing refusal of potentially life-threatening care where capacity was probably lacking.

    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; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate reductions in clinic attendance and dressing changes to the GP

    Wider context from the report

    “Mr Burton did not receive adequate inspections of his wound and changes of dressings when the attendance at the diabetic foot clinic ceased to be weekly or fortnightly. The pandemic was a likely reason for this, but there might be other reasons in future for such changes. There was no evidence at inquest that alternative arrangements and revised care plan was made. The GP did not know of the reduction in clinic attendance or reduction in changes of dressing and assumed others were inspecting the wound and prescribed antibiotics without an examination being done. No witness was able to demonstrate any process of managing a patient who declined necessary potentially life threatening care and probably lacked capacity to make the decision. ”
    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; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a process for managing patients who decline necessary potentially life-threatening care and may lack capacity

    Wider context from the report

    “Mr Burton did not receive adequate inspections of his wound and changes of dressings when the attendance at the diabetic foot clinic ceased to be weekly or fortnightly. The pandemic was a likely reason for this, but there might be other reasons in future for such changes. There was no evidence at inquest that alternative arrangements and revised care plan was made. The GP did not know of the reduction in clinic attendance or reduction in changes of dressing and assumed others were inspecting the wound and prescribed antibiotics without an examination being done. No witness was able to demonstrate any process of managing a patient who declined necessary potentially life threatening care and probably lacked capacity to make the decision. ”
    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; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make alternative arrangements and revise the care plan when clinic attendance changes

    Wider context from the report

    “Mr Burton did not receive adequate inspections of his wound and changes of dressings when the attendance at the diabetic foot clinic ceased to be weekly or fortnightly. The pandemic was a likely reason for this, but there might be other reasons in future for such changes. There was no evidence at inquest that alternative arrangements and revised care plan was made. The GP did not know of the reduction in clinic attendance or reduction in changes of dressing and assumed others were inspecting the wound and prescribed antibiotics without an examination being done. No witness was able to demonstrate any process of managing a patient who declined necessary potentially life threatening care and probably lacked capacity to make the decision. ”
    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; that does not assign responsibility.

    PFD Monitor interpretation

    Prescribing antibiotics without examining the patient

    Wider context from the report

    “Mr Burton did not receive adequate inspections of his wound and changes of dressings when the attendance at the diabetic foot clinic ceased to be weekly or fortnightly. The pandemic was a likely reason for this, but there might be other reasons in future for such changes. There was no evidence at inquest that alternative arrangements and revised care plan was made. The GP did not know of the reduction in clinic attendance or reduction in changes of dressing and assumed others were inspecting the wound and prescribed antibiotics without an examination being done. No witness was able to demonstrate any process of managing a patient who declined necessary potentially life threatening care and probably lacked capacity to make the decision. ”
    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; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain adequate wound inspections and dressing changes when diabetic foot clinic attendance changes

    Wider context from the report

    “Mr Burton did not receive adequate inspections of his wound and changes of dressings when the attendance at the diabetic foot clinic ceased to be weekly or fortnightly. The pandemic was a likely reason for this, but there might be other reasons in future for such changes. There was no evidence at inquest that alternative arrangements and revised care plan was made. The GP did not know of the reduction in clinic attendance or reduction in changes of dressing and assumed others were inspecting the wound and prescribed antibiotics without an examination being done. No witness was able to demonstrate any process of managing a patient who declined necessary potentially life threatening care and probably lacked capacity to make the decision. ”
    Open source report

  2. Inner South London

    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; 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; 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

  3. Inner South London

    AI-generated summary

    Ms Hannah Barney · 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

    Ms Hannah Barney was acutely ill with an infected groin wound and required multidisciplinary care. Surgical debridement was performed on 16 and 18 September, after which she died in intensive care from multi-organ failure associated with extensive soft tissue infection. The report raised concerns about delays in urgent debridement and the absence of 24-hour consultant plastics cover at King’s College 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 King's College Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of a 24-hour consultant plastics service at KCH

    Wider context from the report

    “The plastics surgical consultant, ████████ who saw her on 18th and 21st gave an opinion that she had haematomas and severe sepsis, although the diagnoses of Fournier’s gangrene or necrotising fasciitis had been considered. These conditions needed very urgent surgical treatment. He said that a few days delay in debridement could make a difference to the damage to surrounding tissues. . General surgeons are often reluctant to undertake such debridements and may not have the skills. He opined that having a sole consultant plastics surgeon practitioner in KCH was not safe. In cases of necrotising fasciitis a small delay in surgery would mean death. He noted that KCH was a regional trauma centre. He considered future lives were at risk without a 24 hour consultant plastics service at KCH. ”
    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; that does not assign responsibility.

    PFD Monitor interpretation

    General surgeons' reluctance or lack of skills to undertake debridement

    Wider context from the report

    “The plastics surgical consultant, ████████ who saw her on 18th and 21st gave an opinion that she had haematomas and severe sepsis, although the diagnoses of Fournier’s gangrene or necrotising fasciitis had been considered. These conditions needed very urgent surgical treatment. He said that a few days delay in debridement could make a difference to the damage to surrounding tissues. . General surgeons are often reluctant to undertake such debridements and may not have the skills. He opined that having a sole consultant plastics surgeon practitioner in KCH was not safe. In cases of necrotising fasciitis a small delay in surgery would mean death. He noted that KCH was a regional trauma centre. He considered future lives were at risk without a 24 hour consultant plastics service at KCH. ”
    Open source report

  4. Inner South London

    AI-generated summary

    Constance Connolly · 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

    Constance Connolly died at home on 8 March 2016 from disseminated Nocardia infection, with severe chronic obstructive airways disease also recorded. She declined hospital admission, and planned outpatient investigations were not completed. The report identified concerns about inadequate follow-up, failures in handover and communication, incomplete discharge information, and the failure to arrange a replacement scan appointment, describing these as a system failure in urgent follow-up after discharge from 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 King's College Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to hand over urgent investigation needs to the responsible doctor

    Wider context from the report

    “There are four matters in the circumstances which cause concern 1. The doctor who ordered the scan did not conduct any follow up to see that it had been performed. The consultant chest physician said that handover of care was dangerous time and that it was his duty to do so. 2. The referring doctor notified the GSTT community palliative care team of the need to organize a MRI scan, on the understanding that the team was taking over care. The consultant in the palliative care team explained that their role was to advise the doctor responsible for care, which was at the time, the general practitioner. The referring doctor did not inform the general practitioner. 3. The discharge note to the GP from the A&E indicated a diagnosis of stroke (presumed before CT scan), did not mention the CT finding of cerebral lesions that may be metastases, nor the need for EMI scan and further investigation to conform diagnosis, nor the booking of a MRI scan 4. A member of the palliative care team rang the A&E department and was told that the scan appointment was the next day (17th). When the patient and her mother attended the next day, she was told that there was no appointment. Evidence was heard that the booking, which was on the basis of being an in-patient, is automatically cancelled if the patient becomes an out-patient and the clinical referral cannot be transferred to an outpatient appointment. A new referral and form needed to be completed. So the patient went home, and no further appointment was made. The above evidence suggests a system failure in handover of patients who leave A&E with the need for urgent follow up. ”
    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; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to follow up ordered urgent investigations

    Wider context from the report

    “There are four matters in the circumstances which cause concern 1. The doctor who ordered the scan did not conduct any follow up to see that it had been performed. The consultant chest physician said that handover of care was dangerous time and that it was his duty to do so. 2. The referring doctor notified the GSTT community palliative care team of the need to organize a MRI scan, on the understanding that the team was taking over care. The consultant in the palliative care team explained that their role was to advise the doctor responsible for care, which was at the time, the general practitioner. The referring doctor did not inform the general practitioner. 3. The discharge note to the GP from the A&E indicated a diagnosis of stroke (presumed before CT scan), did not mention the CT finding of cerebral lesions that may be metastases, nor the need for EMI scan and further investigation to conform diagnosis, nor the booking of a MRI scan 4. A member of the palliative care team rang the A&E department and was told that the scan appointment was the next day (17th). When the patient and her mother attended the next day, she was told that there was no appointment. Evidence was heard that the booking, which was on the basis of being an in-patient, is automatically cancelled if the patient becomes an out-patient and the clinical referral cannot be transferred to an outpatient appointment. A new referral and form needed to be completed. So the patient went home, and no further appointment was made. The above evidence suggests a system failure in handover of patients who leave A&E with the need for urgent follow up. ”
    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; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to document significant findings and required follow-up investigations in discharge information

    Wider context from the report

    “There are four matters in the circumstances which cause concern 1. The doctor who ordered the scan did not conduct any follow up to see that it had been performed. The consultant chest physician said that handover of care was dangerous time and that it was his duty to do so. 2. The referring doctor notified the GSTT community palliative care team of the need to organize a MRI scan, on the understanding that the team was taking over care. The consultant in the palliative care team explained that their role was to advise the doctor responsible for care, which was at the time, the general practitioner. The referring doctor did not inform the general practitioner. 3. The discharge note to the GP from the A&E indicated a diagnosis of stroke (presumed before CT scan), did not mention the CT finding of cerebral lesions that may be metastases, nor the need for EMI scan and further investigation to conform diagnosis, nor the booking of a MRI scan 4. A member of the palliative care team rang the A&E department and was told that the scan appointment was the next day (17th). When the patient and her mother attended the next day, she was told that there was no appointment. Evidence was heard that the booking, which was on the basis of being an in-patient, is automatically cancelled if the patient becomes an out-patient and the clinical referral cannot be transferred to an outpatient appointment. A new referral and form needed to be completed. So the patient went home, and no further appointment was made. The above evidence suggests a system failure in handover of patients who leave A&E with the need for urgent follow up. ”
    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; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of referral systems to preserve urgent scan appointments when patients change from in-patient to out-patient status

    Wider context from the report

    “There are four matters in the circumstances which cause concern 1. The doctor who ordered the scan did not conduct any follow up to see that it had been performed. The consultant chest physician said that handover of care was dangerous time and that it was his duty to do so. 2. The referring doctor notified the GSTT community palliative care team of the need to organize a MRI scan, on the understanding that the team was taking over care. The consultant in the palliative care team explained that their role was to advise the doctor responsible for care, which was at the time, the general practitioner. The referring doctor did not inform the general practitioner. 3. The discharge note to the GP from the A&E indicated a diagnosis of stroke (presumed before CT scan), did not mention the CT finding of cerebral lesions that may be metastases, nor the need for EMI scan and further investigation to conform diagnosis, nor the booking of a MRI scan 4. A member of the palliative care team rang the A&E department and was told that the scan appointment was the next day (17th). When the patient and her mother attended the next day, she was told that there was no appointment. Evidence was heard that the booking, which was on the basis of being an in-patient, is automatically cancelled if the patient becomes an out-patient and the clinical referral cannot be transferred to an outpatient appointment. A new referral and form needed to be completed. So the patient went home, and no further appointment was made. The above evidence suggests a system failure in handover of patients who leave A&E with the need for urgent follow up. ”
    Open source report

  5. Inner South London

    AI-generated summary

    Jamie Pashley · 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

    Jamie Pashley died on 26 August 2015 after being found in his flat with high levels of alcohol in his body; the inquest concluded that the death was accidental and caused by alcohol intoxication. The principal concerns were whether people discharged after alcohol detoxification should receive fixed appointments, follow-up telephone contact, and improved access to an alcohol liaison nurse rather than being expected to manage their rehabilitation proactively.

    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; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make telephone contact between discharge and first appointment review

    Wider context from the report

    “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”
    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; that does not assign responsibility.

    PFD Monitor interpretation

    Reliance on individuals to proactively manage their rehabilitation after discharge

    Wider context from the report

    “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”
    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; that does not assign responsibility.

    PFD Monitor interpretation

    Limited availability of hospital alcohol liaison nurse support

    Wider context from the report

    “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”
    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; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide fixed post-discharge appointments after detoxification

    Wider context from the report

    “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed: (1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment; (2) whether telephone contact should also be made with an individual between discharge and first appointment review; (3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient. ”
    Open source report

  6. Inner North London

    AI-generated summary

    Mary Patricia MULDOWNEY · 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

    Mary Patricia Muldowney suffered a spontaneous subarachnoid haemorrhage caused by a ruptured artery and was admitted to East Surrey Hospital on 20 July 2016. Several hospitals refused urgent transfer to specialist neurosurgical care because intensive care beds were unavailable; she was eventually transferred and underwent surgery, but died after her condition deteriorated during transfer. The principal concern was that the lack of an immediately available intensive care bed delayed time-critical surgery, which the report states she probably would have survived if performed promptly.

    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; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of intensive care beds for time-critical specialist neurosurgical transfers

    Wider context from the report

    “In the light of the gravity of Ms Muldowney’s situation, with the only definitive treatment being surgery, she required immediate transfer to a specialist neurosurgical unit, yet she was refused transfer by at least three hospitals who said they had no intensive care beds. She could have been transferred, undergone surgery, spent time in recovery, and then an intensive care bed procured, perhaps even by transferring out a non neurosurgical patient. If such a bed was still unavailable, she could then have been transferred to a different hospital, at least having undergone the time critical clot evacuation and aneurysm clipping. With prompt transfer and surgery, Ms Muldowney would probably have survived. ”
    Open source report

  7. Inner South London

    AI-generated summary

    Rosina Drury · 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

    Rosina Drury, who had several co-morbidities but was described as fit and independent, fell and fractured her hip before undergoing a right hemiarthroplasty. She died from a fat embolism associated with bone cement implantation, described as an unintended consequence of necessary medical treatment. The report raised concern that the absence of pre-operative orthogeriatric review could result in high-risk patients receiving cemented rather than uncemented hemiarthroplasty.

    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; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of pre-operative orthogeriatric review for high-risk patients requiring hemiarthroplasty

    Wider context from the report

    “Does not having a pre-operative orthogeriatric review, recommended by an expert, risk that patients with high risk co-morbidities sometimes have a cemented hemiarthroplasty, when an uncemented one would avoid mortality from bone cement implantation, for which there is no cure or treatment and can be fatal? It is suggested that KCH NHS Foundation Trust may wish to review arrangements for pre-operative review of patients with sub-capital fractured neck of femur requiring fixation with a hemiarthroplasty. ”
    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; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to select uncemented hemiarthroplasty for high-risk patients when cemented arthroplasty presents a bone cement implantation risk

    Wider context from the report

    “Does not having a pre-operative orthogeriatric review, recommended by an expert, risk that patients with high risk co-morbidities sometimes have a cemented hemiarthroplasty, when an uncemented one would avoid mortality from bone cement implantation, for which there is no cure or treatment and can be fatal? It is suggested that KCH NHS Foundation Trust may wish to review arrangements for pre-operative review of patients with sub-capital fractured neck of femur requiring fixation with a hemiarthroplasty. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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