26 Sep 2025 Honoria Culshaw · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Lack of sharing pacemaker wound test results with the surgical team View source
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AI-generated summary
Honoria Culshaw · 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
Honoria Culshaw developed an infected pacemaker site and later underwent surgery to extract the pacemaker. She subsequently developed fatal pneumonia and died on 25 October 2024. The principal concern was that information about a positive wound swab may not have been shared or properly considered, potentially delaying extraction of the pacemaker.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of sharing pacemaker wound test results with the surgical team
Wider context from the report “I heard evidence that on the 15th August 2024, a swab from the pacemaker wound tested positive for the Morganella Morganii bacteria, which was also found post-mortem. It is not clear from the evidence who on the surgical team was made aware of this result, and whether it was properly taken into consideration as part of the pre-operative risk assessment. Mrs. Culshaw had her pacemaker re-sited on the 20th August 2024.
I found that Mrs. Culshaw’s experience of persistent and prolonged infection depleted her physiological reserve and contributed to her succumbing to a fatal pneumonia on the 25th October 2024.
I am concerned that this lack of information sharing of test results , which in this case may have resulted in an extraction process not taking place at the earliest opportunity.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen the wound-swab tracking and review documentation to record swab timing, result review, clinician notification and associated treatment.
Verbatim wording from the response “• A wound swab tracking document managed by the Cardiology Catheter Laboratory (CCL) team has been strengthened. This includes a daily check, details of results received, and which clinicians have been informed.” Source location Response from Lancashire Teaching Hospitals NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add wound-swab results to the WHO checklist, using an interim sticker until the revised form is approved, redesigned and printed.
Verbatim wording from the response “• “Wound swab check” has been added to the WHO checklist.¹ The WHO checklist is carried out immediately prior to the procedure with the participation of the full team undertaking the procedure.” Source location Response from Lancashire Teaching Hospitals NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Microbiology telephone notification was not required because the superficial wound swab result did not meet critical-result reporting criteria.
Verbatim wording from the response “Progress: Microbiology advise they will telephone through critical results about virulent organisms such as group A streptococcus, or if it is from a normally sterile site, or if the organism has resistant markers of national concern.” Source location Response from Lancashire Teaching Hospitals NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Harris Flex cannot automatically alert clinicians to pathology results, limiting automated result notification while IT work continues.
Verbatim wording from the response “The electronic system in place at the Trust does not have a facility to automatically alert the clinician and therefore there is a risk on the risk register (Datix ID 2176) ‘Harris Flex currently does not follow, or support UK medical workflows leading to delay or missed review of Pathology results’.” Source location Response from Lancashire Teaching Hospitals NHS Foundation Trust
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Concerns raised 4 Lack of understanding among non-stroke specialist clinicians about when and where thrombectomy services are available View source Lack of regional mutual aid for thrombectomy View source Lack of a clear plan to deliver a 24/7 thrombectomy service in Lancashire View source Failure to deliver a 24/7 thrombectomy service in Lancashire View source See 1 more concern
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AI-generated summary
Michelle Julie Marie Michaela MASON · 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
Michelle Julie Marie Michaela MASON died on 1 June 2024 at Royal Infirmary, Lancaster, after sudden onset of lack of vision, vomiting and severe pain. She was reviewed around six hours later, when thrombolysis was no longer possible; thrombectomy was considered but no local service was available and transfer was considered too late. Concerns included the absence of a 24/7 thrombectomy service in Lancashire, limited understanding among non-stroke specialists about thrombectomy availability, and a lack of regional mutual aid.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding among non-stroke specialist clinicians about when and where thrombectomy services are available
Wider context from the report “(2) There is a lack of understanding from non-stroke specialist clinicians in Lancashire as to when and where thrombectomy services are available for patients in Lancashire
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regional mutual aid for thrombectomy
Wider context from the report “(3) There is no mutual aid regionally , even where thrombectomy is available, clinically appropriate, it is known lack the procedure is likely to result in death and it is anticipated resources are available to complete the procedure.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear plan to deliver a 24/7 thrombectomy service in Lancashire
Wider context from the report “(1) NHS England national service specifications provide for a 24/7 thrombectomy service which is not currently being delivered in Lancashire and there is no clear plan to deliver that 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to deliver a 24/7 thrombectomy service in Lancashire
Wider context from the report “(1) NHS England national service specifications provide for a 24/7 thrombectomy service which is not currently being delivered in Lancashire and there is no clear plan to deliver that service
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce thrombectomy availability communications and monitor clinician awareness through feedback, refreshing information as service arrangements change.
Verbatim wording from the response “The updated document was issued on 13th June 2025 and disseminated through formal communications channels, including via Chief Operating Officers in July 2025. The Trust will continue to reinforce the communication and monitor understanding and awareness through feedback mechanisms and will refresh communications as the service evolves.” Source location Response from Lancashire Teaching Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete radiographer shift planning and consultation to support 24/7 thrombectomy provision.
Verbatim wording from the response “• Continued recruitment across Anaesthetics, Radiology, and Radiography;” Source location Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor progress against the 24/7 service and regional-aid plans through monthly executive review.
Verbatim wording from the response “Progress against these actions will be monitored on a monthly basis by the executive management team and an earlier start date will be considered if possible.” Source location Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Convene a regional stakeholder meeting with Salford Royal Hospital and The Walton Centre to scope coordinated mutual aid.
Verbatim wording from the response “The Walton Centre also responded positively on 15th July 2025, and a regional meeting involving all three organisations has been scheduled by 22 August 2025 to progress a coordinated regional aid approach.” Source location Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conducted initial regional-aid discussions and assessed the impact of potential support on Salford Royal services.
Verbatim wording from the response “Salford Royal Hospital responded positively, and a meeting was held on 15th July 2025, with participation from the Northwest Medical Director for Commissioning. This was a constructive discussion that outlined the key requirements and challenges for regional aid.” Source location Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalise and agree the 24/7 thrombectomy business case, including required infrastructure and workforce arrangements.
Verbatim wording from the response “• Finalisation of a business case to be agreed with NHSE to support the required infrastructure and workforce;” Source location Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Negotiate and evaluate a sustainable 1-in-8 neurointerventional radiology rota and associated job plans for 24/7 service delivery.
Verbatim wording from the response “NIR engagement and Business Case Development” Source location Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish regional mutual-aid arrangements by engaging neighbouring thrombectomy centres and progressing a coordinated support agreement.
Verbatim wording from the response “The Trust fully recognises the critical importance of regional aid to ensure timely access to thrombectomy for patients in Lancashire and South Cumbria, particularly during the overnight period (22:00–08:00) when local provision is not yet available.” Source location Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop operational readiness for overnight theatre and recovery services.
Verbatim wording from the response “• Development of operational readiness for overnight theatre and recovery services.” Source location Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a seven-day mechanical thrombectomy service until 22:00, with the planned transition to full 24/7 provision by 28 February 2026.
Verbatim wording from the response “the service began operating into the evening delivering 7 days per week including Bank Holidays with cover until 22:00 with some occasional gaps due to workforce availability, supported by collaborative working across Anaesthetics, Theatres, and Radiology. From 13 June 2025 cover have been consistently achieved from 08.00-22.00 (referral cut off times are 20.00 for all sites with the exception of Harrogate at 19.30). This has been achieved by flexible use of existing staff rotas, interim arrangements with Anaesthetic and Theatre teams, and a shared commitment across departments to maximise available NIR clinical time.” Source location Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit additional Radiology and Anaesthetic staff required to support overnight thrombectomy provision.
Verbatim wording from the response “• Continued recruitment across Anaesthetics, Radiology, and Radiography;” Source location Response from Lancashire Teaching Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and disseminate stakeholder communications explaining current thrombectomy service hours and referral availability.
Verbatim wording from the response “The Trust acknowledges this concern and has taken steps to improve awareness and clarity across the system. The stakeholder communications policy has been updated to reflect the current operational hours of the mechanical thrombectomy service. This update has been broadened to include non-stroke clinical teams across the region, ensuring that all relevant clinicians are informed of when and where thrombectomy is available.” Source location Response from Lancashire Teaching Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop operational readiness for overnight theatre and recovery services supporting thrombectomy.
Verbatim wording from the response “• Development of operational readiness for overnight theatre and recovery services.” Source location 2025-0268 - Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete recruitment and rota development for Anaesthetic, Radiology and Radiography staffing needed for overnight provision.
Verbatim wording from the response “• Continued recruitment across Anaesthetics, Radiology, and Radiography;” Source location 2025-0268 - Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evaluate and negotiate the proposed 1-in-8 NIR consultant rota and associated job plans for sustainable 24/7 coverage.
Verbatim wording from the response “A meeting held on the 27th June with national stakeholders, including the Chair of the United Kingdom Neuro-Interventional Group (UKNG), explored national models for 24/7 service delivery and shared sample rota structures. The NIR team were asked to provide feedback on preferred rota models and job plan implications, with a response received in the week commencing 21st July 2025.” Source location 2025-0268 - Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish regional thrombectomy aid arrangements by contacting neighbouring providers, assessing options and convening a stakeholder meeting.
Verbatim wording from the response “Following receipt of the Regulation 28 notice, the Trust has escalated efforts to establish regional aid arrangements with neighbouring centres. Actions taken include Direct contact by the LTHTR Chief Operating Officer with Salford Royal Hospital, and CEO-to-CEO correspondence issued to both Salford Royal Hospital and The Walton Centre, formally requesting regional support.” Source location 2025-0268 - Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a seven-day mechanical thrombectomy service with coverage from 08:00 to 22:00, including bank holidays.
Verbatim wording from the response “the service began operating into the evening delivering 7 days per week including Bank Holidays with cover until 22:00 with some occasional gaps due to workforce availability, supported by collaborative working across Anaesthetics, Theatres, and Radiology. From 13 June 2025 cover have been consistently achieved from 08.00-22.00 (referral cut off times are 20.00 for all sites with the exception of barest at 19.30). This has been achieved by flexible use of existing staff rotas, interim arrangements with Anaesthetic and Theatre teams, and a shared commitment across departments to maximise available NIR clinical time.” Source location 2025-0268 - Response from Lancashire Teaching Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a fully operational 24/7 mechanical thrombectomy service at LTHTR by 28 February 2026.
Verbatim wording from the response “These actions form part of a clear and accountable plan to implement a fully operational 24/7 thrombectomy service by 28 February 2026, ensuring equitable access for all patients across Lancashire and South Cumbria. There is a commitment to starting this sooner if staff can be recruited to enable this.” Source location 2025-0268 - Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and disseminate stakeholder communications explaining current mechanical thrombectomy service hours and referral availability.
Verbatim wording from the response “The Trust acknowledges this concern and has taken steps to improve awareness and clarity across the system. The stakeholder communications policy has been updated to reflect the current operational hours of the mechanical thrombectomy service. This update has been broadened to include non-stroke clinical teams across the region, ensuring that all relevant clinicians are informed of when and where thrombectomy is available.” Source location 2025-0268 - Response from Lancashire Teaching Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalise the business case for 24/7 thrombectomy expansion, including required infrastructure and workforce arrangements.
Verbatim wording from the response “• Finalisation of a business case to be agreed with NHSE to support the required infrastructure and workforce;” Source location 2025-0268 - Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A 24/7 service cannot yet be implemented because NIR rota approval, recruitment, radiographer planning, and overnight theatre and recovery readiness remain incomplete.
Verbatim wording from the response “While progress has been made with evening and weekend expansion, a 24/7 service is not yet in place. The barriers are multi-factorial and include:” Source location Response from Lancashire Teaching Hospitals
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regional mutual aid is not currently agreed because neighbouring services face fragility and logistical challenges across the North West.
Verbatim wording from the response “Outside of these hours, owing to the fragility of services and logistical challenges across the North West, there is currently no agreement to provide mutual aid from Manchester or Liverpool. There has been an initial meeting chaired by the Medical Director for North West specialised commissioning at NHS England and a further date has been agreed to discuss progressing this further on 22nd August 2025.” Source location Response from Lancashire Teaching Hospitals
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A 24/7 thrombectomy service cannot yet be implemented because the NIR rota, recruitment, staffing and overnight operational arrangements remain incomplete.
Verbatim wording from the response “While progress has been made with evening and weekend expansion, a 24/7 service is not yet in place. The barriers are multi-factorial and include:” Source location 2025-0268 - Response from Lancashire Teaching Hospitals
Open published response
Concerns raised 3 Lack of nursing knowledge about when basic asthma assessments should be taken View source Failure to request assistance from a specialist ward for asthma care View source Failure to escalate problems identified by treating nurses to senior nursing staff 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.
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AI-generated summary
Marina Sharon Young · 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
Marina Sharon Young, who had spina bifida and asthma, died after spending 39 hours in the Accident & Emergency Department during an asthma attack. The report describes failures in medical management, escalation to specialist teams, nursing assessment, and provision of care for her complex needs, including catheterisation, pressure-area care and toileting. The concerns include inadequate assessment and management of patients held in A&E beyond the expected time, insufficient asthma expertise, and failures to escalate concerns.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of nursing knowledge about when basic asthma assessments should be taken
Wider context from the report “4. Asthma is a common condition. However, A & E lacked nurses with any knowledge of when basic assessment such as peak flow should be taken and no request for assistance from a specialist ward was made.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to request assistance from a specialist ward for asthma care
Wider context from the report “4. Asthma is a common condition. However, A & E lacked nurses with any knowledge of when basic assessment such as peak flow should be taken and no request for assistance from a specialist ward was made .
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate problems identified by treating nurses to senior nursing staff
Wider context from the report “5. Although the nursing staff made attempts to engage the acute medical team, no attempt was made to escalate problems identified by the treating nurses to senior nursing staff
” Open source report
Concerns raised 6 Failure to seek urgent clinical assistance for significant per rectum bleeding View source Inadequate nursing handovers failing to ensure appropriate risks are managed and prioritised View source Inadequate nursing records View source Inadequate assessment of compliance with procedural changes and expectations View source Failure of doctors to prioritise work by reviewing the task book for urgent tasks View source Failure to request medical review verbally when appropriate 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.
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AI-generated summary
Margaret Clement · 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
Margaret Clement, aged 92, died at Royal Blackburn Hospital on 15 June 2022 after developing significant rectal bleeding, vomiting blood and an upper gastrointestinal bleed following hospital admission after a fall. Concerns included inadequate nursing records and handovers, ineffective prioritisation of urgent tasks, failure to seek urgent clinical assistance for significant rectal bleeding, and inadequate assessment of compliance with procedural changes.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek urgent clinical assistance for significant per rectum bleeding
Wider context from the report “(5) Nursing staff failed to seek urgent clinical assistance when presented with a significant per rectum bleed
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate nursing handovers failing to ensure appropriate risks are managed and prioritised
Wider context from the report “(2)Evidence was heard that nursing handovers were inadequate and did not ensure appropriate risks were managed and prioritised
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate nursing records
Wider context from the report “(1) Evidence was heard that nursing records on Reedyford ward were inadequate in a number of respects including recording the wrong medication, requesting a medical review for the wrong patient and not recording when an urgent review was needed in the doctor's task book
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate assessment of compliance with procedural changes and expectations
Wider context from the report “(6) Inadequate measures have been taken to assess compliance with procedural changes and expectations that have been set following the Trust investigation into this matter
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of doctors to prioritise work by reviewing the task book for urgent tasks
Wider context from the report “(3)Evidence was heard that doctors on the ward did not effectively prioritise work by reviewing the task book in order to identify more urgent tasks
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to request medical review verbally when appropriate
Wider context from the report “(4)Nurs staff failed to request medical review verbally where it was appropriate to do so, relying on a task book .
” Open source report
15 Jan 2024 Rhys Lennon Hill · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 9 Lack of clarity on VTE prophylaxis for patients who are both bariatric and neurosurgical View source Unclear responsibility and system for reconciling community and hospital medications View source Failure to record escalation of omitted critical medicines in the notes View source Limited nursing-team understanding of when to instigate the hospital passport system View source Incomplete clinical and nursing documentation View source Unclear governance of safe discharge decisions from the neurosurgical ward View source Lack of a clear escalation process for omitted critical medicines View source Failure to follow and understand the VTE policy for discharge risk reduction View source Failure to share key patient information between clinicians and the nursing team View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Rhys Lennon Hill · 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
Rhys Lennon Hill underwent spinal surgery and was discharged from Royal Preston Hospital on 30 January 2023. He collapsed at home on 9 February 2023 and attempts to resuscitate him were unsuccessful; a post-mortem examination found that he died from a pulmonary embolus due to a deep vein thrombosis. The principal concerns included failure to escalate his refusal of Dalteparin or assess the associated risk, failure to provide required VTE information at discharge, and wider problems with communication, documentation, medication reconciliation, and discharge processes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity on VTE prophylaxis for patients who are both bariatric and neurosurgical
Wider context from the report “8. The VTE policy of the trust is based on the NICE guidance. The inquest identified that there is a difference in approach on the use of prophylaxis for a surgical bariatric patient and a neuro surgical patient. Where there is a bariatric patient who is a neuro surgical patient there does not appear to be any clarity on how the challenges should be approached to reduce the risk of VTE as far as possible .
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility and system for reconciling community and hospital medications
Wider context from the report “5. The evidence was that the system and responsibility between the hospital pharmacy and clinicians for reconciling medications given in the community with those given in the hospital to ensure all necessary medications were given was unclear . As a consequence, Rhys did not receive his ADHD medication;
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record escalation of omitted critical medicines in the notes
Wider context from the report “4. Despite a critical medicine being not given to Rhys there appeared to be no clear policy on how that would be escalated to a senior nurse/ treating clinician and how that escalation would be captured in the notes ;
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited nursing-team understanding of when to instigate the hospital passport system
Wider context from the report “6. There appeared to be limited understanding amongst the nursing team of when a hospital “passport” system should be instigated for someone who was admitted with a “passport”;
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete clinical and nursing documentation
Wider context from the report “2. Documentation (clinical and nursing) was incomplete and did not detail key/important information about Rhys. This included ward round notes containing limited information which meant it was difficult to know what matters had been considered as part of discharge planning and what information was known to the clinicians;
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear governance of safe discharge decisions from the neurosurgical ward
Wider context from the report “7. The system for deciding when a discharge form the neuro surgical ward was safe was unclear . The evidence appeared to suggest that the Physiotherapy team took responsibility for it if they assessed mobility at a suitable level. It was unclear how that was overseen and fitted with the responsibility of the treating clinician ;
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear escalation process for omitted critical medicines
Wider context from the report “4. Despite a critical medicine being not given to Rhys there appeared to be no clear policy on how that would be escalated to a senior nurse/ treating clinician and how that escalation would be captured in the notes;
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow and understand the VTE policy for discharge risk reduction
Wider context from the report “3. The VTE policy was not fully followed and there was evidence that there was limited understanding by staff of precisely what the trust policy required in relation to reducing the risk at discharge of VTE;
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share key patient information between clinicians and the nursing team
Wider context from the report “1. The inquest heard evidence that communication between clinicians and the nursing team on the neurosurgical ward was not effective . The teams appeared to operate in silos and key information about patients did not appear to have been shared between the teams ;
” Open source report
26 Sep 2018 Angela Mary Jackson · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure to provide accurate referral destination information for aortic aneurysm treatment View source Lack of approved documented pathways for referral and treatment of aortic aneurysms 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.
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AI-generated summary
Angela Mary Jackson · 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
Angela Mary Jackson died at the Royal Albert Edward Infirmary, Wigan, after being admitted with chest and abdominal pain and found to have an extensive thoracic aortic aneurysm. She suffered a cardiac arrest and died while discussions about referral to an appropriate specialist centre were ongoing. The report identified concerns about incorrect and delayed referrals and the absence of clear, documented pathways for managing and referring patients with aortic aneurysms.
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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate referral destination information for aortic aneurysm treatment
Wider context from the report “i. The treatment of an aortic aneurysm depends on the position of the aneurysm. In general terms aneurysms above the diaphragm are referred to as thoracic aneurysms and should be treated by cardiothoracic surgeons and aneurysms below the diaphragm are referred to as abdominal aneurysms and should be treated by vascular surgeons.
The treatment of a thoracic aneurysm by a Cardiothoracic Surgeon may also depend on the position of the aneurysm above the diaphragm. An ascending thoracic aneurysm could be dealt with by local Cardiothoracic Surgeons at the Wythenshawe Hospital in Greater Manchester, whereas a descending thoracic aneurysm should be referred to and managed by the Regional Aortic Centre in Liverpool, namely the Liverpool Hospital.
ii. The Wythenshawe Hospital referred to the Liverpool Hospital as the Liverpool Heart Centre and advised the Wigan Hospital to contact the Liverpool Heart Centre. Clearly, the Liverpool Heart Centre does not exist and the correct referral should have been to the Liverpool Heart and Chest Hospital.
iii. There are no written protocols or pathways in relation to the treatment of aortic aneurysms in Greater Manchester or the North West of England, although the Preston Hospital has started to prepare a written Acute Aortic Syndrome Pathway. However, the Acute Aortic Syndrome Path is only in draft form, which has not been approved and which is not in existence.
iv. The absence of documented pathways in relation to the treatment of aortic aneurysms is a national problem, which needs to be addressed to enable local district hospitals to be aware of the pathway and to have clear, unequivocal direction for referral of patients with appropriate and correct lines of referral, including the correct names of hospitals and direct telephone numbers and email addresses to ensure efficient and expedient referrals to appropriate hospitals and appropriate surgical teams.
v. The referral of patients for the treatment of aortic aneurysm, in many cases, requires an urgent referral and emergency treatment and in my opinion there is a risk that future deaths will occur unless action is taken to consider clear and unequivocal pathways for the referral of patients requiring such treatment.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of approved documented pathways for referral and treatment of aortic aneurysms
Wider context from the report “i. The treatment of an aortic aneurysm depends on the position of the aneurysm. In general terms aneurysms above the diaphragm are referred to as thoracic aneurysms and should be treated by cardiothoracic surgeons and aneurysms below the diaphragm are referred to as abdominal aneurysms and should be treated by vascular surgeons.
The treatment of a thoracic aneurysm by a Cardiothoracic Surgeon may also depend on the position of the aneurysm above the diaphragm. An ascending thoracic aneurysm could be dealt with by local Cardiothoracic Surgeons at the Wythenshawe Hospital in Greater Manchester, whereas a descending thoracic aneurysm should be referred to and managed by the Regional Aortic Centre in Liverpool, namely the Liverpool Hospital.
ii. The Wythenshawe Hospital referred to the Liverpool Hospital as the Liverpool Heart Centre and advised the Wigan Hospital to contact the Liverpool Heart Centre. Clearly, the Liverpool Heart Centre does not exist and the correct referral should have been to the Liverpool Heart and Chest Hospital.
iii. There are no written protocols or pathways in relation to the treatment of aortic aneurysms in Greater Manchester or the North West of England , although the Preston Hospital has started to prepare a written Acute Aortic Syndrome Pathway. However, the Acute Aortic Syndrome Path is only in draft form, which has not been approved and which is not in existence.
iv. The absence of documented pathways in relation to the treatment of aortic aneurysms is a national problem , which needs to be addressed to enable local district hospitals to be aware of the pathway and to have clear, unequivocal direction for referral of patients with appropriate and correct lines of referral, including the correct names of hospitals and direct telephone numbers and email addresses to ensure efficient and expedient referrals to appropriate hospitals and appropriate surgical teams.
v. The referral of patients for the treatment of aortic aneurysm, in many cases, requires an urgent referral and emergency treatment and in my opinion there is a risk that future deaths will occur unless action is taken to consider clear and unequivocal pathways for the referral of patients requiring such treatment.
” Open source report
Concerns raised 14 Deficient procedures for determining which nurse clinicians may lead a nursing shift View source Lack of knowledge of the clinical effects of substantial hepatic compromise during haemorrhagic admission View source Failure to complete the fluid balance chart View source Failure to provide adequate and timely resuscitation for hypovolaemia View source Unavailability of consultant ENT input in complex ENT cases View source Failure by ENT surgeons to recognise the complexity of haemorrhagic cases with hepatic failure and coagulopathy View source Failure to select treatment appropriate for facial fractures View source Failure to direct resuscitation in accordance with documented medical plans View source Failure to disclose relevant clinical care issues in the ENT consultant's statement View source Failure to document events after a peri-arrest View source Lack of knowledge and recognition of early signs of hypovolaemia View source Failure to seek medical team input for management of complex haemorrhagic admissions View source Failure to obtain ENT input before mortality review conclusions View source Failure to seek medical direction on future management after a peri-arrest View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Michael John NEWELL · 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
Michael John Newell died following an admission involving haemorrhage, decompensated liver failure and associated coagulopathy. Concerns included a lack of awareness among emergency and surgical staff of the significance of his liver failure, inadequate recognition and treatment of hypovolaemia, lack of consultant ENT input, weaknesses in the mortality review process, and nursing documentation and management issues.
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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deficient procedures for determining which nurse clinicians may lead a nursing shift
Wider context from the report “(5) the conduct of the Nurse in charge of the ward of making no notes after her presence at a peri-arrest, neither seeking or obtaining any direction from the medical team as to future management, not directing any further resuscitation in accordance with documented medical plans in the notes and lack of completion of the fluid balance chart would suggest that the Trust's procedures for determining which nurse clinicians may lead a nursing shift should be reviewed .
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of the clinical effects of substantial hepatic compromise during haemorrhagic admission
Wider context from the report “(1) the Accident & Emergency staff, neurosurgeons and ENT surgeons of various grades were unaware of the substantial effect that Mr Newell's decompensated liver failure would have on his clinical course and subsequent management . No input was sought from any medical team to assist in the management prior to Mr Newell's first collapse at 11:14 AM on 5 May 2014. This lack of awareness raises significant concerns about the knowledge base of Accident & Emergency and surgical junior staff of the significant effect of substantial underlying hepatic compromise may have on any form of admission with some form of haemorrhage . As a result, the family were completely unaware of the significance of Mr Newell's admission due to the lack of awareness by attending clinicians.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the fluid balance chart
Wider context from the report “(5) the conduct of the Nurse in charge of the ward of making no notes after her presence at a peri-arrest, neither seeking or obtaining any direction from the medical team as to future management, not directing any further resuscitation in accordance with documented medical plans in the notes and lack of completion of the fluid balance chart would suggest that the Trust's procedures for determining which nurse clinicians may lead a nursing shift should be reviewed.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate and timely resuscitation for hypovolaemia
Wider context from the report “(2) the junior ENT surgeons and neurosurgeons showed a startling lack of knowledge of the early signs of hypovolaemia and, if any did realise, made no attempt to treat Mr Newell adequately . Whilst this PFD report is primarily sent with regard to the death of Mr Newell, this has been a feature over a number of years of other cases where hypovolaemia was not appropriately diagnosed and late resuscitation ensued .
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of consultant ENT input in complex ENT cases
Wider context from the report “(3) there was a worrying lack by the ENT surgeons to realise the complexity of the case due to the ongoing haemorrhage, decompensated liver failure and associated coagulopathy, that there were no base of skull fractures and to select a method of treatment with Rapid Rhino Pack's that in the view of the ENT expert was only appropriate as a first-line measure and not for facial fractures. Firstly, there was no consultant ENT input into Mr Newell's case at any point prior to his death . Secondly, none of the above issues were brought to the attention of the Court in the ENT consultant's statement raising issues within the Trust for improving patient care.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by ENT surgeons to recognise the complexity of haemorrhagic cases with hepatic failure and coagulopathy
Wider context from the report “(3) there was a worrying lack by the ENT surgeons to realise the complexity of the case due to the ongoing haemorrhage, decompensated liver failure and associated coagulopathy , that there were no base of skull fractures and to select a method of treatment with Rapid Rhino Pack's that in the view of the ENT expert was only appropriate as a first-line measure and not for facial fractures. Firstly, there was no consultant ENT input into Mr Newell's case at any point prior to his death. Secondly, none of the above issues were brought to the attention of the Court in the ENT consultant's statement raising issues within the Trust for improving patient care.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to select treatment appropriate for facial fractures
Wider context from the report “(3) there was a worrying lack by the ENT surgeons to realise the complexity of the case due to the ongoing haemorrhage, decompensated liver failure and associated coagulopathy, that there were no base of skull fractures and to select a method of treatment with Rapid Rhino Pack's that in the view of the ENT expert was only appropriate as a first-line measure and not for facial fractures . Firstly, there was no consultant ENT input into Mr Newell's case at any point prior to his death. Secondly, none of the above issues were brought to the attention of the Court in the ENT consultant's statement raising issues within the Trust for improving patient care.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to direct resuscitation in accordance with documented medical plans
Wider context from the report “(5) the conduct of the Nurse in charge of the ward of making no notes after her presence at a peri-arrest, neither seeking or obtaining any direction from the medical team as to future management, not directing any further resuscitation in accordance with documented medical plans in the notes and lack of completion of the fluid balance chart would suggest that the Trust's procedures for determining which nurse clinicians may lead a nursing shift should be reviewed.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disclose relevant clinical care issues in the ENT consultant's statement
Wider context from the report “(3) there was a worrying lack by the ENT surgeons to realise the complexity of the case due to the ongoing haemorrhage, decompensated liver failure and associated coagulopathy, that there were no base of skull fractures and to select a method of treatment with Rapid Rhino Pack's that in the view of the ENT expert was only appropriate as a first-line measure and not for facial fractures. Firstly, there was no consultant ENT input into Mr Newell's case at any point prior to his death. Secondly, none of the above issues were brought to the attention of the Court in the ENT consultant's statement raising issues within the Trust for improving patient care.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document events after a peri-arrest
Wider context from the report “(5) the conduct of the Nurse in charge of the ward of making no notes after her presence at a peri-arrest , neither seeking or obtaining any direction from the medical team as to future management, not directing any further resuscitation in accordance with documented medical plans in the notes and lack of completion of the fluid balance chart would suggest that the Trust's procedures for determining which nurse clinicians may lead a nursing shift should be reviewed.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge and recognition of early signs of hypovolaemia
Wider context from the report “(2) the junior ENT surgeons and neurosurgeons showed a startling lack of knowledge of the early signs of hypovolaemia and, if any did realise, made no attempt to treat Mr Newell adequately. Whilst this PFD report is primarily sent with regard to the death of Mr Newell, this has been a feature over a number of years of other cases where hypovolaemia was not appropriately diagnosed and late resuscitation ensued.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek medical team input for management of complex haemorrhagic admissions
Wider context from the report “(1) the Accident & Emergency staff, neurosurgeons and ENT surgeons of various grades were unaware of the substantial effect that Mr Newell's decompensated liver failure would have on his clinical course and subsequent management. No input was sought from any medical team to assist in the management prior to Mr Newell's first collapse at 11:14 AM on 5 May 2014. This lack of awareness raises significant concerns about the knowledge base of Accident & Emergency and surgical junior staff of the significant effect of substantial underlying hepatic compromise may have on any form of admission with some form of haemorrhage. As a result, the family were completely unaware of the significance of Mr Newell's admission due to the lack of awareness by attending clinicians.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain ENT input before mortality review conclusions
Wider context from the report “(4) the Trust's ENT team made no input into the mortality review prior to reaching its conclusions . Alternatively, the mortality review team made no request for ENT input prior to reaching its conclusions . Either formulation reduces the effectiveness of the mortality review .
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek medical direction on future management after a peri-arrest
Wider context from the report “(5) the conduct of the Nurse in charge of the ward of making no notes after her presence at a peri-arrest, neither seeking or obtaining any direction from the medical team as to future management , not directing any further resuscitation in accordance with documented medical plans in the notes and lack of completion of the fluid balance chart would suggest that the Trust's procedures for determining which nurse clinicians may lead a nursing shift should be reviewed.
” Open source report
Concerns raised 2 Failure to provide consistent prophylaxis for patients with lower limb immobilisation View source Lack of a venous thromboembolism risk assessment tool for patients discharged with lower limb immobilisation 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
Sharon Louise Henshall · 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
Sharon Louise Henshall sustained a fractured ankle while skiing in Italy and died in the early hours of 18 February 2015 after collapsing from a pulmonary embolus. The report raised concerns that there was no venous thromboembolism risk-assessment tool or interim process for patients discharged with lower-limb immobilisation, and that access to prophylaxis varied between hospitals.
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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistent prophylaxis for patients with lower limb immobilisation
Wider context from the report “The evidence of both ████████ Consultant in Emergency Medicine, and ████████ Consultant Physician, was that there is currently no venothromboembolism risk assessment model in place in the Emergency Department to assess the risk of VTE in patients discharged with lower limb immobilisation. The reason for this appeared to be that the evidence base regarding risk factors and success of prophylaxis is poor.
████████ accepted that Sharon Louise Henshall should have been assessed. His evidence was that he and colleagues were working on developing a tool that would try to extrapolate data from the inpatient assessment tools to create an outpatient tool, but that it was difficult to know what benefit would be derived from giving prophylactic treatment.
Dr McDowell's evidence was that creating a risk assessment tool would be a very easy thing to do, but that it would require a "major change in pathways," which would need to involve primary care to monitor complications.
(1) To have no assessment in place at all and to offer nothing in an area of known risks on the basis that the evidence base is varied, as opposed to having a tool in place, even one that recognises only the highest and obviously known/understood risk factors, seems unlikely to be adequate, and gives rise to a concern that future deaths will occur;
(2) To have no interim tool in place pending the outcome of a 'major change in pathways' seems unlikely to be adequate;
(3) Dr McDowell's evidence was that other European countries routinely give LMWH to patients with lower limb immobilisation, yet this is not something that is done at LTHtr, or uniformly across Trusts in England and Wales ;
(4) According to ████████ the NICE guidance in this area, which was updated in June 2015, states that clinicians should have a discussion about risks and benefits with each individual, which necessarily requires having some form of tool or model in place to facilitate that discussion, yet there is no such tool in place within LTHtr;
(5) The evidence of both ████████████████████ was that whether patients will be offered prophylaxis varies according to which hospital patients attend, since some Trusts offer it and some Trusts do not , and different Trusts have differing risk assessment tools taking different risk factors into account. It is of concern that due to the absence of national guidance there appears to be something of a 'postcode lottery' with regards to prophylaxis being offered or not .
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a venous thromboembolism risk assessment tool for patients discharged with lower limb immobilisation
Wider context from the report “The evidence of both ████████ Consultant in Emergency Medicine, and ████████ Consultant Physician, was that there is currently no venothromboembolism risk assessment model in place in the Emergency Department to assess the risk of VTE in patients discharged with lower limb immobilisation . The reason for this appeared to be that the evidence base regarding risk factors and success of prophylaxis is poor.
████████ accepted that Sharon Louise Henshall should have been assessed. His evidence was that he and colleagues were working on developing a tool that would try to extrapolate data from the inpatient assessment tools to create an outpatient tool, but that it was difficult to know what benefit would be derived from giving prophylactic treatment.
Dr McDowell's evidence was that creating a risk assessment tool would be a very easy thing to do, but that it would require a "major change in pathways," which would need to involve primary care to monitor complications.
(1) To have no assessment in place at all and to offer nothing in an area of known risks on the basis that the evidence base is varied, as opposed to having a tool in place, even one that recognises only the highest and obviously known/understood risk factors, seems unlikely to be adequate, and gives rise to a concern that future deaths will occur;
(2) To have no interim tool in place pending the outcome of a 'major change in pathways' seems unlikely to be adequate ;
(3) Dr McDowell's evidence was that other European countries routinely give LMWH to patients with lower limb immobilisation, yet this is not something that is done at LTHtr, or uniformly across Trusts in England and Wales;
(4) According to ████████ the NICE guidance in this area, which was updated in June 2015, states that clinicians should have a discussion about risks and benefits with each individual, which necessarily requires having some form of tool or model in place to facilitate that discussion, yet there is no such tool in place within LTHtr ;
(5) The evidence of both ████████████████████ was that whether patients will be offered prophylaxis varies according to which hospital patients attend, since some Trusts offer it and some Trusts do not, and different Trusts have differing risk assessment tools taking different risk factors into account. It is of concern that due to the absence of national guidance there appears to be something of a 'postcode lottery' with regards to prophylaxis being offered or not.
” Open source report
Concerns raised 1 Failure to advise patients of the risk of death from pituitary surgery 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
Mary Anne Gemma Hanson · 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 Anne Gemma Hanson underwent elective surgery to remove a large pituitary tumour on 27 June 2014 and died on 15 August 2014 after developing a postoperative bleed and failing to recover despite further treatment. Concerns included inadequate recording and communication of surgical risks and benefits, lack of patient information materials, incomplete capacity and best-interests documentation, and uncertainty about whether the staff nurse completing the assessment was suitably qualified.
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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to advise patients of the risk of death from pituitary surgery
Wider context from the report “(1) Mary Hanson had been seen in combined pituitary clinic by ████████ consultant neurosurgeon, and ████████ consultant endocrinologist on 2 June 2014. Although ████████ evidence was that the risks of surgery would have been clearly explained to both Mary Hanson and her daughter ████████ at that consultation, and that he would have stressed that the risk of serious harm and death is very small, ████████ evidence was that they had not been advised of a risk of death by any clinician , and that her knowledge as to the risk of death was because of her own research carried out on the internet;
” Open source report
27 Nov 2014 Freda Virginia Owens · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 5 Unrecognised incorrect assumptions about the cause of a patient’s injury View source Failure to examine a high-risk patient area View source Delays in involving the tissue viability specialist View source Failure to provide relevant patient information to involved medical professionals View source Failure to communicate clinical assessment information between relevant specialist teams View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Freda Virginia Owens · 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
Freda Virginia Owens, aged 93, died after developing bronchopneumonia associated with an infected necrotic pressure ulcer of the left hip, alongside burns and scalds sustained on 2 November 2012. The report identified concerns about the gathering and exchange of information between care and medical professionals, delays in recognising the pressure ulcer, and the resulting delay in treatment.
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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unrecognised incorrect assumptions about the cause of a patient’s injury
Wider context from the report “I now write to the two Hospital Trusts and to the Croft House Rest Home to confirm that in my view action should be taken because there is a concern about the quality of the gathering and exchange of information between the various medical professionals involved in Mrs. Owens’s care for the following reasons:
1. A District Nurse was unaware of potentially important information as regards the Patient including how restricted her movement was.
2. Having considered all of the oral evidence in court and the clinical records, the amount and quality of the information provided to the hospital is limited and this had an impact upon later decisions taken and not least by the Tissue Viability Nurse once she was involved.
3. Although the District Nurse explained why she did not examine the Deceased’s left hip area on 21st November 2012, the Nurse in my view ought to have examined that area given the Patient was viewed as being at high risk of developing pressure areas. Such examination may have prompted her, given her professional experience, to recognise a pressure area as distinct from a burn / scald and that information may then have been communicated on to hospital staff who would have then most likely involved the Tissue Viability Nurse more quickly reducing the chances of an incorrect assumption being made that the hip area was problematic as a result of a pressure area and not due to burns inflicted on 2nd November 2012. However, having chosen not to do so this was not then communicated to other medical professionals involved in her care for them to assess.
4. That following arrival and assessment at the Royal Preston Hospital, that there was a lack of communication between the clinical team and the plastic surgery team, which appears to have contributed to the fact that it was not until 3rd December 2012 when the Tissue Viability Nurse became involved.
These issues as regards the gathering and exchange of information as regards this Patient raise concerns that an incorrect assumption – such as the one made that Mrs Owens hip area was damaged due to the incident involving the commode on 2nd November 2012 - may arise in a future case and with fatal consequences if such an incorrect assumption were not to be recognised early enough to positively affect a Patient’s outcome .
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to examine a high-risk patient area
Wider context from the report “I now write to the two Hospital Trusts and to the Croft House Rest Home to confirm that in my view action should be taken because there is a concern about the quality of the gathering and exchange of information between the various medical professionals involved in Mrs. Owens’s care for the following reasons:
1. A District Nurse was unaware of potentially important information as regards the Patient including how restricted her movement was.
2. Having considered all of the oral evidence in court and the clinical records, the amount and quality of the information provided to the hospital is limited and this had an impact upon later decisions taken and not least by the Tissue Viability Nurse once she was involved.
3. Although the District Nurse explained why she did not examine the Deceased’s left hip area on 21st November 2012, the Nurse in my view ought to have examined that area given the Patient was viewed as being at high risk of developing pressure areas . Such examination may have prompted her, given her professional experience, to recognise a pressure area as distinct from a burn / scald and that information may then have been communicated on to hospital staff who would have then most likely involved the Tissue Viability Nurse more quickly reducing the chances of an incorrect assumption being made that the hip area was problematic as a result of a pressure area and not due to burns inflicted on 2nd November 2012. However, having chosen not to do so this was not then communicated to other medical professionals involved in her care for them to assess.
4. That following arrival and assessment at the Royal Preston Hospital, that there was a lack of communication between the clinical team and the plastic surgery team, which appears to have contributed to the fact that it was not until 3rd December 2012 when the Tissue Viability Nurse became involved.
These issues as regards the gathering and exchange of information as regards this Patient raise concerns that an incorrect assumption – such as the one made that Mrs Owens hip area was damaged due to the incident involving the commode on 2nd November 2012 - may arise in a future case and with fatal consequences if such an incorrect assumption were not to be recognised early enough to positively affect a Patient’s outcome.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in involving the tissue viability specialist
Wider context from the report “I now write to the two Hospital Trusts and to the Croft House Rest Home to confirm that in my view action should be taken because there is a concern about the quality of the gathering and exchange of information between the various medical professionals involved in Mrs. Owens’s care for the following reasons:
1. A District Nurse was unaware of potentially important information as regards the Patient including how restricted her movement was.
2. Having considered all of the oral evidence in court and the clinical records, the amount and quality of the information provided to the hospital is limited and this had an impact upon later decisions taken and not least by the Tissue Viability Nurse once she was involved.
3. Although the District Nurse explained why she did not examine the Deceased’s left hip area on 21st November 2012, the Nurse in my view ought to have examined that area given the Patient was viewed as being at high risk of developing pressure areas. Such examination may have prompted her, given her professional experience, to recognise a pressure area as distinct from a burn / scald and that information may then have been communicated on to hospital staff who would have then most likely involved the Tissue Viability Nurse more quickly reducing the chances of an incorrect assumption being made that the hip area was problematic as a result of a pressure area and not due to burns inflicted on 2nd November 2012. However, having chosen not to do so this was not then communicated to other medical professionals involved in her care for them to assess.
4. That following arrival and assessment at the Royal Preston Hospital, that there was a lack of communication between the clinical team and the plastic surgery team, which appears to have contributed to the fact that it was not until 3rd December 2012 when the Tissue Viability Nurse became involved .
These issues as regards the gathering and exchange of information as regards this Patient raise concerns that an incorrect assumption – such as the one made that Mrs Owens hip area was damaged due to the incident involving the commode on 2nd November 2012 - may arise in a future case and with fatal consequences if such an incorrect assumption were not to be recognised early enough to positively affect a Patient’s outcome.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide relevant patient information to involved medical professionals
Wider context from the report “I now write to the two Hospital Trusts and to the Croft House Rest Home to confirm that in my view action should be taken because there is a concern about the quality of the gathering and exchange of information between the various medical professionals involved in Mrs. Owens’s care for the following reasons:
1. A District Nurse was unaware of potentially important information as regards the Patient including how restricted her movement was.
2. Having considered all of the oral evidence in court and the clinical records, the amount and quality of the information provided to the hospital is limited and this had an impact upon later decisions taken and not least by the Tissue Viability Nurse once she was involved.
3. Although the District Nurse explained why she did not examine the Deceased’s left hip area on 21st November 2012, the Nurse in my view ought to have examined that area given the Patient was viewed as being at high risk of developing pressure areas. Such examination may have prompted her, given her professional experience, to recognise a pressure area as distinct from a burn / scald and that information may then have been communicated on to hospital staff who would have then most likely involved the Tissue Viability Nurse more quickly reducing the chances of an incorrect assumption being made that the hip area was problematic as a result of a pressure area and not due to burns inflicted on 2nd November 2012. However, having chosen not to do so this was not then communicated to other medical professionals involved in her care for them to assess.
4. That following arrival and assessment at the Royal Preston Hospital, that there was a lack of communication between the clinical team and the plastic surgery team, which appears to have contributed to the fact that it was not until 3rd December 2012 when the Tissue Viability Nurse became involved.
These issues as regards the gathering and exchange of information as regards this Patient raise concerns that an incorrect assumption – such as the one made that Mrs Owens hip area was damaged due to the incident involving the commode on 2nd November 2012 - may arise in a future case and with fatal consequences if such an incorrect assumption were not to be recognised early enough to positively affect a Patient’s outcome.
” 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 Lancashire Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate clinical assessment information between relevant specialist teams
Wider context from the report “I now write to the two Hospital Trusts and to the Croft House Rest Home to confirm that in my view action should be taken because there is a concern about the quality of the gathering and exchange of information between the various medical professionals involved in Mrs. Owens’s care for the following reasons:
1. A District Nurse was unaware of potentially important information as regards the Patient including how restricted her movement was.
2. Having considered all of the oral evidence in court and the clinical records, the amount and quality of the information provided to the hospital is limited and this had an impact upon later decisions taken and not least by the Tissue Viability Nurse once she was involved.
3. Although the District Nurse explained why she did not examine the Deceased’s left hip area on 21st November 2012, the Nurse in my view ought to have examined that area given the Patient was viewed as being at high risk of developing pressure areas. Such examination may have prompted her, given her professional experience, to recognise a pressure area as distinct from a burn / scald and that information may then have been communicated on to hospital staff who would have then most likely involved the Tissue Viability Nurse more quickly reducing the chances of an incorrect assumption being made that the hip area was problematic as a result of a pressure area and not due to burns inflicted on 2nd November 2012. However, having chosen not to do so this was not then communicated to other medical professionals involved in her care for them to assess.
4. That following arrival and assessment at the Royal Preston Hospital, that there was a lack of communication between the clinical team and the plastic surgery team , which appears to have contributed to the fact that it was not until 3rd December 2012 when the Tissue Viability Nurse became involved.
These issues as regards the gathering and exchange of information as regards this Patient raise concerns that an incorrect assumption – such as the one made that Mrs Owens hip area was damaged due to the incident involving the commode on 2nd November 2012 - may arise in a future case and with fatal consequences if such an incorrect assumption were not to be recognised early enough to positively affect a Patient’s outcome.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations