3 Jun 2025 Benjamin Finch Arnold · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 6 Unequal provision of maternity services between LGI and SJUH View source Ambiguity about the classification and operating parameters of the SJUH maternity unit View source Limited nursing and medical support available to the SJUH site View source Lack of standardised guidelines for performing LISA procedures View source Insufficient national guidelines for identifying and treating reversible causes of cardiac arrest in newborn babies View source Lack of on-site paediatric cover at SJUH View source See 3 more concerns
Responses linked to these concerns
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AI-generated summary
Benjamin Finch Arnold · 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
Benjamin Finch Arnold was born prematurely at Saint James’ University Hospital after his mother was redirected there because the intended delivery unit was closed due to lack of capacity. He developed breathing difficulties during a LISA procedure, suffered bilateral pneumothoraces and a subsequent right-sided tension pneumothorax, and died after a devastating brain injury caused by prolonged low oxygen levels. The concerns included the organisation and classification of maternity services, the lack of standardised guidance for LISA procedures and newborn cardiac arrest, and updates to the hospital risk register.
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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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unequal provision of maternity services between LGI and SJUH
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH , with, for example, no on-site paediatric cover at SJUH. What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon, was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ambiguity about the classification and operating parameters of the SJUH maternity unit
Wider context from the report “(2) The evidence at the inquest disclosed an ambiguity as to whether the SJUH maternity unit, officially a “Level 1” centre, was operating outside the parameters of that classification . That ambiguity was demonstrated by a witness (whose evidence was admitted in writing under R23 due to her poor health) who described it as a “Level 2” unit , and by a witness in person who described it as a “Level 1 and a half” unit, which last classification does not exist . LTHT to respond.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Limited nursing and medical support available to the SJUH site
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH, with, for example, no on-site paediatric cover at SJUH. What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon , was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised guidelines for performing LISA procedures
Wider context from the report “(3) The evidence disclosed concerns that guidelines for the performing of a LISA procedure are not standardised across the NHS , particularly with reference to the performing of a chest x-ray to exclude pneumothorax before commencing the procedure , and to the necessity of seeking consultant approval before undertaking the procedure . BAPM, RCPCH, RCUK and NN all to respond.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient national guidelines for identifying and treating reversible causes of cardiac arrest in newborn babies
Wider context from the report “(4) The evidence disclosed concerns whether national guidelines on the reversible causes of cardiac arrest (the “4 H’s and 4 T’s”) were sufficient for the purposes of identifying and treating the potential causes of cardiac arrest in a newborn baby . BAPM, RCPCH, RCUK and NN all to respond.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of on-site paediatric cover at SJUH
Wider context from the report “(1) The provision of maternity services across the Leeds Teaching Hospitals Trust (LTHT) continues to be split unequally between LGI and SJUH, with, for example, no on-site paediatric cover at SJUH . What was described by LTHT witnesses as the “isolation” of the SJUH site, particularly as it related to the limited nursing and medical support that can be called upon, was a recurrent theme in the inquest. The inquest was told that a long held ambition to bring LTHT’s maternity services under one roof had been recently frustrated by the announcement that the building of a new hospital for Leeds would not begin until 2030. Secretary of State for Health and Social Care to respond.
” 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 Recruit additional consultants and advanced clinical practitioners to strengthen neonatal staffing.
Verbatim wording from the response “In efforts to mitigate the risks, in 2023, three new consultants were appointed (two in post, one pending), which improved staffing levels, although these gains were partially offset by reduced hours among existing consultants. A business case was submitted to increase the consultant workforce to 18 whole-time equivalents (WTE). This would enable the development of a dedicated weekend rota at SJUH and allow for 24-hour resident consultant cover at LGI, in accordance with the recommendations of BAPM. Despite recruitment progress, staffing levels remained insufficient, and the risk score remained unchanged at 16.” Source location Response from Leeds Teaching Hospitals NHS 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 Establish an Executive-led group to review the neonatal care model and safe staffing across both sites.
Verbatim wording from the response “In June 2025, the RMC received an update following the January 2025 CQC inspection. A new Executive-led group was established to review the neonatal care model and ensure safe, sustainable services at both sites, including appropriate clinical staffing. The Children’s CSU committed to a full review of the risk, working alongside Specialist Commissioners and the ODN to clarify controls, identify ongoing gaps, and develop further mitigation strategies.” Source location Response from Leeds Teaching Hospitals NHS 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 Implement clinical protocols, including intensive and high-dependency care centralisation, daily safety huddles, consultant-led cover and transfer of sick neonates to LGI.
Verbatim wording from the response “Clinical protocols were adjusted with the unit functioning as a SCU while all intensive care (ICU) and high dependency (HDU) activity was centralised to the L43 unit at LGI. The Trust introduced a joint maternity and neonatal clinical dashboard, reviewed at the Maternity Services Clinical Governance Forum, which helped monitor incidents and inform decision-making. Daily safety huddles between neonatal and maternity teams were introduced to proactively plan for high-risk births, alongside consultant-led cover where junior doctor gaps occurred. A protocol was also implemented to transfer sick neonates born at SJUH to LGI.” Source location Response from Leeds Teaching Hospitals NHS 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 Complete a full review of neonatal service risks, controls, gaps and mitigation strategies with commissioners and the ODN.
Verbatim wording from the response “In June 2025, the RMC received an update following the January 2025 CQC inspection. A new Executive-led group was established to review the neonatal care model and ensure safe, sustainable services at both sites, including appropriate clinical staffing. The Children’s CSU committed to a full review of the risk, working alongside Specialist Commissioners and the ODN to clarify controls, identify ongoing gaps, and develop further mitigation strategies.” Source location Response from Leeds Teaching Hospitals NHS 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 Remind SJUH staff of the unit’s designation and operating criteria.
Verbatim wording from the response “To prevent any possible misunderstandings, staff at SJUH have been reminded of the unit’s designation and the criteria it follows. Ongoing education and training on this topic will continue.” Source location Response from Leeds Teaching Hospitals NHS 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 Seek formal redesignation of SJUH as a Level 2 local neonatal unit.
Verbatim wording from the response “SJUH is currently designated as a SCU i.e. a Level 1 centre but with added service specifications which have been agreed with the network. It is therefore termed as a “Special Care Unit plus” (SCU+), indicating that it operates under agreed service specification variations with the network. This includes delivery of non-invasive respiratory support and use of central lines. The delivery criteria are set as that of a SCU i.e. delivery at >32 weeks gestation only and >34 weeks gestation if multiple pregnancy.” Source location Response from Leeds Teaching Hospitals NHS Trust
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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 Submit a business case to increase the consultant workforce to 18 whole-time equivalents.
Verbatim wording from the response “In efforts to mitigate the risks, in 2023, three new consultants were appointed (two in post, one pending), which improved staffing levels, although these gains were partially offset by reduced hours among existing consultants. A business case was submitted to increase the consultant workforce to 18 whole-time equivalents (WTE). This would enable the development of a dedicated weekend rota at SJUH and allow for 24-hour resident consultant cover at LGI, in accordance with the recommendations of BAPM. Despite recruitment progress, staffing levels remained insufficient, and the risk score remained unchanged at 16.” Source location Response from Leeds Teaching Hospitals NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue education and training on SJUH’s designation and operating criteria.
Verbatim wording from the response “To prevent any possible misunderstandings, staff at SJUH have been reminded of the unit’s designation and the criteria it follows. Ongoing education and training on this topic will continue.” Source location Response from Leeds Teaching Hospitals NHS 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 Maintain and regularly review the neonatal services risk register, including controls, mitigations and risk scores.
Verbatim wording from the response “The Trust welcomes the opportunity to provide a comprehensive account of the amendments made to the risk register following Benjamin’s death. The Trust’s risk register is a core tool used across Clinical Service Units (CSUs) to identify, assess, and manage risks to patient safety and service delivery. The risk specific to neonatal services was recorded on the Trust’s Datix system on 28 January 2014 and has remained under continuous review by both the CSU and the Trust’s Risk Management Committee (RMC).” Source location Response from Leeds Teaching Hospitals NHS 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 Rewrite training rotas and enhance pay and banding support for Advanced Nurse Practitioners.
Verbatim wording from the response “Subsequently and particularly during 2022, pressures on service provision increased significantly due to a 50% reduction in the number of registrars available to contribute to the on-call rotas. In response, the Trust took the decision to reduce the number of cots at the LGI to mitigate this risk. While this aimed to stabilise staffing, it also had potential consequences for families and babies across the Yorkshire and Humber region. Several actions were initiated, including re-writing of training rotas, improved support for Advanced Nurse Practitioners (ANPs) through pay and banding enhancements, and Executive Director-approved variation orders for payment. There was a recognised need for additional investment in the consultant workforce, particularly while services continued to operate at both the SJUH and LGI sites.” Source location Response from Leeds Teaching Hospitals NHS Trust
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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 SJUH is formally designated a Level 1 SCU+ with agreed service variations, rather than operating under an undefined intermediate classification.
Verbatim wording from the response “SJUH is currently designated as a SCU i.e. a Level 1 centre but with added service specifications which have been agreed with the network. It is therefore termed as a “Special Care Unit plus” (SCU+), indicating that it operates under agreed service specification variations with the network. This includes delivery of non-invasive respiratory support and use of central lines. The delivery criteria are set as that of a SCU i.e. delivery at >32 weeks gestation only and >34 weeks gestation if multiple pregnancy.” Source location Response from Leeds Teaching Hospitals NHS Trust
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19 Sep 2024 Evelyn Grace March · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1 Premature discharge after prolonged labour and induced delivery View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Evelyn Grace March · 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
Evelyn Grace March was born after a prolonged labour and was discharged home with her parents four hours later. The following night, while being breastfed in her mother’s bed, she was found unresponsive and could not be revived. The report raises concerns about maternal exhaustion, the early discharge after prolonged labour, and the risk of accidental suffocation while a sleeping adult was in bed with the baby.
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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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Premature discharge after prolonged labour and induced delivery
Wider context from the report “4. Consideration should be given to the wisdom of discharging a mother so soon after a prolonged labour and induced delivery . Had she been permitted to sleep in hospital for a few hours knowing that her baby was being monitored, the tragedy may have been avoided.
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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 Immediate postnatal care and discharge were considered compliant with national guidance, so earlier discharge arrangements were not changed.
Verbatim wording from the response “I respectfully note that you state that consideration should be given to the wisdom of discharging a mother so soon after a prolonged labour and delivery.” Source location Response from Leeds Teaching Hospitals
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19 Jul 2023 Carole MCQUINN · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 10 Failure to record post-discharge infection concerns View source Failure to record clinical observations during hospital attendance View source Failure to record inter-hospital clinical communications View source Failure to arrange follow-up appointments at discharge View source Failure to escalate suspected infection concerns to the treating team View source Failure to provide discharge medications View source Lack of discharge notes View source Failure to ensure swab results are reviewed View source Failure to seek specialist input from the Leeds treating team View source Safety hazard associated with evening hospital discharges View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 7
Action
Contact York surgical colleagues to explain communication arrangements and discuss measures to prevent similar coordination failures.
Stated completedThe respondent said that this action was complete when they made their response on 21 July 2023. View source
Action
Use Patient Pass to coordinate and record referrals, information requests and advice between hospitals and specialist departments.
Stated completedThe respondent said that this action was complete when they made their response on 21 July 2023. View source
Action
Require staff to record recent post-discharge contacts, advice, investigations and clinicians in PPM+, and forward review requests to outpatient teams.
Stated completedThe respondent said that this action was complete when they made their response on 21 July 2023. View source
Action
Operate a quality-improvement collaborative supporting earlier ward discharges and monthly tracking of discharge performance and EDAN provision.
Stated completedThe respondent said that this action was complete when they made their response on 21 July 2023. View source
Action
Amend the electronic discharge-note template to include required discharge information and advice.
Stated completedThe respondent said that this action was complete when they made their response on 21 July 2023. View source
Action
Disseminate discharge-advice guidance and train registered nurses in its use.
Stated plannedThe respondent said that this action was planned when they made their response on 21 July 2023. View source
Action
Provide AMS CSU patients with discharge notes, booked follow-up appointments, wound-care plans, medication or supplies, and community-support instructions.
Stated completedThe respondent said that this action was complete when they made their response on 21 July 2023. View source See 4 more actions
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AI-generated summary
Carole MCQUINN · 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
Carole MCQUINN underwent pancreatic surgery in February 2022 and subsequently experienced pancreatic leakage, abdominal collections and prolonged hospital treatment. After discharge without a discharge note, medication or follow-up appointment, concerns about infection were not adequately recorded or escalated, and a positive swab result was not reviewed until several days later. She was later admitted with suspected intra-abdominal sepsis and was found unresponsive in hospital; the inquest concluded that she died from a pulmonary embolism likely related to post-operative infection, inflammation and immobility.
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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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record post-discharge infection concerns
Wider context from the report “2. Trust staff interacting with the deceased and her daughter regarding infection concerns arising in the post-discharge period between 21/4/22 and 3/5/22 made no records of the same . Nursing staff were shown photographs of the deceased's drain site, and issued stoma bags and a swab to her daughter for suspected infection, but did not flag this development to the treating team or make arrangements for the results of the swabs to be reviewed. No clinical observations of the deceased were recorded when she attended the hospital on 3/5/22. The swab result did not come to anyone's attention or get reviewed until the deceased's daughter flagged the issue to staff on 3/5/22. These omissions led to missed opportunities for earlier assessment and treatment of the deceased.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinical observations during hospital attendance
Wider context from the report “2. Trust staff interacting with the deceased and her daughter regarding infection concerns arising in the post-discharge period between 21/4/22 and 3/5/22 made no records of the same. Nursing staff were shown photographs of the deceased's drain site, and issued stoma bags and a swab to her daughter for suspected infection, but did not flag this development to the treating team or make arrangements for the results of the swabs to be reviewed. No clinical observations of the deceased were recorded when she attended the hospital on 3/5/22 . The swab result did not come to anyone's attention or get reviewed until the deceased's daughter flagged the issue to staff on 3/5/22. These omissions led to missed opportunities for earlier assessment and treatment of the deceased.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record inter-hospital clinical communications
Wider context from the report “3. The deceased had an emergency admission to York Hospital on 4/5/22 with suspected intra-abdominal sepsis. A York doctor was verbally tasked with communicating with the surgical team at Leeds to report back on a comparison of CT scans from both hospitals. No record of this contact - which was verbally reported in positive terms - was made by either hospital and no evidence could be provided as to who had spoken to whom and in what terms . Further, despite the lengthy and complex treatment the deceased had undergone in Leeds, and her attendance there the day prior to admission to York, no contact was made by the treating team at York with the treating team at Leeds, to allow for additional specialist input into the deceased's management and consideration of possible transfer of 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange follow-up appointments at discharge
Wider context from the report “1. The deceased was discharged from hospital on the evening of 20th April 2022 with no discharge note, medications or follow-up appointment. I heard evidence that evening discharges are a cause for concern for the Trust itself, and that while consideration is being given to ensuring follow-up appointments are set on discharge, this is not yet currently in place . Trust staff were falsely reassured in this case that the deceased had this safety net in place when she did 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate suspected infection concerns to the treating team
Wider context from the report “2. Trust staff interacting with the deceased and her daughter regarding infection concerns arising in the post-discharge period between 21/4/22 and 3/5/22 made no records of the same. Nursing staff were shown photographs of the deceased's drain site, and issued stoma bags and a swab to her daughter for suspected infection, but did not flag this development to the treating team or make arrangements for the results of the swabs to be reviewed. No clinical observations of the deceased were recorded when she attended the hospital on 3/5/22. The swab result did not come to anyone's attention or get reviewed until the deceased's daughter flagged the issue to staff on 3/5/22. These omissions led to missed opportunities for earlier assessment and treatment of the deceased.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide discharge medications
Wider context from the report “1. The deceased was discharged from hospital on the evening of 20th April 2022 with no discharge note, medications or follow-up appointment. I heard evidence that evening discharges are a cause for concern for the Trust itself, and that while consideration is being given to ensuring follow-up appointments are set on discharge, this is not yet currently in place. Trust staff were falsely reassured in this case that the deceased had this safety net in place when she did 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of discharge notes
Wider context from the report “1. The deceased was discharged from hospital on the evening of 20th April 2022 with no discharge note , medications or follow-up appointment. I heard evidence that evening discharges are a cause for concern for the Trust itself, and that while consideration is being given to ensuring follow-up appointments are set on discharge, this is not yet currently in place. Trust staff were falsely reassured in this case that the deceased had this safety net in place when she did 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure swab results are reviewed
Wider context from the report “2. Trust staff interacting with the deceased and her daughter regarding infection concerns arising in the post-discharge period between 21/4/22 and 3/5/22 made no records of the same. Nursing staff were shown photographs of the deceased's drain site, and issued stoma bags and a swab to her daughter for suspected infection, but did not flag this development to the treating team or make arrangements for the results of the swabs to be reviewed . No clinical observations of the deceased were recorded when she attended the hospital on 3/5/22. The swab result did not come to anyone's attention or get reviewed until the deceased's daughter flagged the issue to staff on 3/5/22 . These omissions led to missed opportunities for earlier assessment and treatment of the deceased.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek specialist input from the Leeds treating team
Wider context from the report “3. The deceased had an emergency admission to York Hospital on 4/5/22 with suspected intra-abdominal sepsis. A York doctor was verbally tasked with communicating with the surgical team at Leeds to report back on a comparison of CT scans from both hospitals. No record of this contact - which was verbally reported in positive terms - was made by either hospital and no evidence could be provided as to who had spoken to whom and in what terms. Further, despite the lengthy and complex treatment the deceased had undergone in Leeds, and her attendance there the day prior to admission to York, no contact was made by the treating team at York with the treating team at Leeds , to allow for additional specialist input into the deceased's management and consideration of possible transfer of 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Safety hazard associated with evening hospital discharges
Wider context from the report “1. The deceased was discharged from hospital on the evening of 20th April 2022 with no discharge note, medications or follow-up appointment. I heard evidence that evening discharges are a cause for concern for the Trust itself , and that while consideration is being given to ensuring follow-up appointments are set on discharge, this is not yet currently in place. Trust staff were falsely reassured in this case that the deceased had this safety net in place when she did not.
” 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 Contact York surgical colleagues to explain communication arrangements and discuss measures to prevent similar coordination failures.
Verbatim wording from the response “Since the death, and in response to your report, senior members of the team have made contact with colleagues in the surgical team in York to explain the arrangements in place and to discuss the issues raised by this case so that both trusts can work together to avoid similar problems arising in the future.” Source location Response from Leeds 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 Use Patient Pass to coordinate and record referrals, information requests and advice between hospitals and specialist departments.
Verbatim wording from the response “Since this death the AMS CSU has started to use new IT software (Patient Pass) to improve coordination and recording of requests for information and advice. Patient Pass is a two-way messaging tool that is used to facilitate referrals and improve communication between hospitals and specialist departments. It is relied on by a number of specialist teams in LTHT to speed up referrals and support clinical process reliability. It improves record keeping as details of referrals and responses are automatically saved onto patients’ PPM+ records and it also provides the organisation with a full audit trail for information governance purposes.” Source location Response from Leeds 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 Require staff to record recent post-discharge contacts, advice, investigations and clinicians in PPM+, and forward review requests to outpatient teams.
Verbatim wording from the response “The problems that arose in this case have been discussed at ward meetings. Staff have been instructed that all contact with recently discharged patients and their relatives must be recorded on the Trust’s electronic case record system PPM+ for the first 7 days after discharge at least. Notes made must include details of advice given, any investigations undertaken or arranged and the clinicians involved. Staff have also been informed that requests for advice or review should be forwarded to the outpatient team to facilitate early face to face assessment, coordination of any additional investigations, formal review of results and appropriate communication with the patient and family members afterwards.” Source location Response from Leeds 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 Operate a quality-improvement collaborative supporting earlier ward discharges and monthly tracking of discharge performance and EDAN provision.
Verbatim wording from the response “The Trust recognises the difficulties that can arise when patients leave hospital late on the day of discharge and it is committed to improving discharging practice throughout the organisation. A Quality Improvement collaborative led by a specialist quality improvement practitioner is in place to support wards to achieve the majority of discharges before 3pm. By using data and metrics the Trust can track all wards’ progress towards this target each month and it can also check that EDANs have been sent with patients at the point of discharge. AMS CSU is part of this collaborative and it will continue to work to improve its practice.” Source location Response from Leeds 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 Amend the electronic discharge-note template to include required discharge information and advice.
Verbatim wording from the response “Since this review all staff involved in the discharge process have been informed of the team’s requirements, including providing patients with (a) a paper copy of their discharge note on leaving the ward even if medication has yet to be dispensed, (b) the date and time of outpatient follow-up appointments, (c) wound care plans, (d) supplies of medication, dressings etc. They have been reminded of their responsibility for making appropriate arrangements for community resources such as district nursing and the need for clear instructions about repeat prescriptions in the discharge summary. The document template for the electronic discharge note (EDAN) has also been amended to ensure that all relevant information and advice is included and can be reviewed by patients, their relatives and their GPs.” Source location Response from Leeds 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 Disseminate discharge-advice guidance and train registered nurses in its use.
Verbatim wording from the response “Following the hearing and in response to your report the CSU has reviewed the steps taken to improve discharging practice and it has drafted Good Practice Guidance for the completion of discharge advice notes by registered nurses (please see attachment 2). Dissemination of this guidance, with training for staff, will be complete by the end of October 2023. Support to embed good practice will also be provided by the CSU quality practitioners and the clinical education team by the end of November 2023. The guidance has already been discussed with the nursing staff at the CSU Perfect Ward meeting (where all matrons and ward sisters meet each month to review all quality indicators and incidents within the CSU) and ward sisters are now sharing it with their staff in each ward area.” Source location Response from Leeds Teaching Hospitals NHS Foundation Trust
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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 Provide AMS CSU patients with discharge notes, booked follow-up appointments, wound-care plans, medication or supplies, and community-support instructions.
Verbatim wording from the response “Since this review all staff involved in the discharge process have been informed of the team’s requirements, including providing patients with (a) a paper copy of their discharge note on leaving the ward even if medication has yet to be dispensed, (b) the date and time of outpatient follow-up appointments, (c) wound care plans, (d) supplies of medication, dressings etc. They have been reminded of their responsibility for making appropriate arrangements for community resources such as district nursing and the need for clear instructions about repeat prescriptions in the discharge summary. The document template for the electronic discharge note (EDAN) has also been amended to ensure that all relevant information and advice is included and can be reviewed by patients, their relatives and their GPs.” Source location Response from Leeds Teaching Hospitals NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust has no record or recollection of any communication from York Hospital about the deceased’s admission.
Verbatim wording from the response “3. As explained in the evidence for the inquest the Trust has no record of contact made by clinicians from York Hospital about the deceased’s admission there on Wednesday 4/5/22 or on Thursday 5/5/22 and no member of the surgical team recalls a discussion about the deceased with anyone in York on either day.” Source location Response from Leeds Teaching Hospitals NHS Foundation Trust
Open published response
18 Aug 2022 John Francis Heffron · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 12 Failure to establish whether bank and agency staff hold current resuscitation training View source Failure to ensure nursing staff are trained and familiar with emergency systems for responding to patient collapse View source Failure to obtain timely and adequate evidence during serious incident investigations View source Failure to establish the nursing qualifications of bank and agency staff permitted to work in the ED View source Failure to assess workload and staffing levels in serious incident investigations View source Failure to ensure serious incident investigations are conducted by suitably trained and experienced investigators View source Failure to ensure serious incident investigations are conducted independently View source Failure to require nursing agencies to supply professionally qualified staff View source Failure to require nursing agencies to supply staff who have undergone appropriate ED induction View source Failure to require nursing agencies to supply staff with current training to specified standards View source Failure to provide a suitable induction system for bank and agency staff to become familiar with the crash call system View source Lack of audits and spot checks verifying bank and agency nurses’ familiarity with crash call procedures View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
John Francis Heffron · 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
John Francis Heffron, a 50-year-old wheelchair user, was found confused in his flat and later suffered a cardiac arrest while alone in an A&E cubicle. There was a delay in initiating CPR, including delays in making a crash call and ascertaining his DNAR status; he was resuscitated but sustained a hypoxic brain injury and died in hospital. The concerns included bank and agency nursing staff’s familiarity with emergency procedures, training and induction, and the adequacy and independence of the Trust’s investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish whether bank and agency staff hold current resuscitation training
Wider context from the report “(6) It was unclear what steps had been taken by the Trust prior to 12 December 2021 to establish:
(i) the nursing qualifications of bank and/or agency staff permitted to work in the ED
(ii) whether bank and/or agency staff hold appropriate and current training in resuscitation procedures
(iii) whether a suitable induction system was in place to ensure bank and/or agency staff were familiar with the crash call system
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure nursing staff are trained and familiar with emergency systems for responding to patient collapse
Wider context from the report “(5) Evidence taken at the inquest indicated the collapse and/or death of a patient in the ED is known to occur sometimes. It is a foreseeable risk. Hence there is a need for the nursing staff to be trained and familiar with the emergency systems in place, in order to be able to respond appropriately .
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain timely and adequate evidence during serious incident investigations
Wider context from the report “(7) The Trust saw the need to initiate a “Serious Incident Investigation” but allocated this work to a person
(i) present in the ED at the time of the incident, and thus not independent of the events being examined
(ii) who had not been trained in such investigations save for a one-day course some five years previously and had never undertaken one of this nature before
(iii) who spoke to the staff involved during the shift on the night of the incident, only when time permitted, alongside their other work. No written statements were obtained. In consequence, the precise chronology of events is unclear
(iv) no context was provided which may have enabled an assessment of the workload or staffing levels in the ED at the material time
For these reasons the inquest felt unable to rely upon the conclusions reached in the Serious Incident Investigation Report
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the nursing qualifications of bank and agency staff permitted to work in the ED
Wider context from the report “(6) It was unclear what steps had been taken by the Trust prior to 12 December 2021 to establish:
(i) the nursing qualifications of bank and/or agency staff permitted to work in the ED
(ii) whether bank and/or agency staff hold appropriate and current training in resuscitation procedures
(iii) whether a suitable induction system was in place to ensure bank and/or agency staff were familiar with the crash call system
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess workload and staffing levels in serious incident investigations
Wider context from the report “(7) The Trust saw the need to initiate a “Serious Incident Investigation” but allocated this work to a person
(i) present in the ED at the time of the incident, and thus not independent of the events being examined
(ii) who had not been trained in such investigations save for a one-day course some five years previously and had never undertaken one of this nature before
(iii) who spoke to the staff involved during the shift on the night of the incident, only when time permitted, alongside their other work. No written statements were obtained. In consequence, the precise chronology of events is unclear
(iv) no context was provided which may have enabled an assessment of the workload or staffing levels in the ED at the material time
For these reasons the inquest felt unable to rely upon the conclusions reached in the Serious Incident Investigation Report
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure serious incident investigations are conducted by suitably trained and experienced investigators
Wider context from the report “(7) The Trust saw the need to initiate a “Serious Incident Investigation” but allocated this work to a person
(i) present in the ED at the time of the incident, and thus not independent of the events being examined
(ii) who had not been trained in such investigations save for a one-day course some five years previously and had never undertaken one of this nature before
(iii) who spoke to the staff involved during the shift on the night of the incident, only when time permitted, alongside their other work. No written statements were obtained. In consequence, the precise chronology of events is unclear
(iv) no context was provided which may have enabled an assessment of the workload or staffing levels in the ED at the material time
For these reasons the inquest felt unable to rely upon the conclusions reached in the Serious Incident Investigation Report
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure serious incident investigations are conducted independently
Wider context from the report “(7) The Trust saw the need to initiate a “Serious Incident Investigation” but allocated this work to a person
(i) present in the ED at the time of the incident, and thus not independent of the events being examined
(ii) who had not been trained in such investigations save for a one-day course some five years previously and had never undertaken one of this nature before
(iii) who spoke to the staff involved during the shift on the night of the incident, only when time permitted, alongside their other work. No written statements were obtained. In consequence, the precise chronology of events is unclear
(iv) no context was provided which may have enabled an assessment of the workload or staffing levels in the ED at the material time
For these reasons the inquest felt unable to rely upon the conclusions reached in the Serious Incident Investigation Report
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to require nursing agencies to supply professionally qualified staff
Wider context from the report “(9) It was unclear whether the Trust’s contractual arrangements with nursing agencies stipulate the requirement for those supplied to
(a) be professionally qualified
(b) have current training to specified standards and
(c) have undergone appropriate induction to the ED.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to require nursing agencies to supply staff who have undergone appropriate ED induction
Wider context from the report “(9) It was unclear whether the Trust’s contractual arrangements with nursing agencies stipulate the requirement for those supplied to
(a) be professionally qualified
(b) have current training to specified standards and
(c) have undergone appropriate induction to the ED .
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to require nursing agencies to supply staff with current training to specified standards
Wider context from the report “(9) It was unclear whether the Trust’s contractual arrangements with nursing agencies stipulate the requirement for those supplied to
(a) be professionally qualified
(b) have current training to specified standards and
(c) have undergone appropriate induction to the ED.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a suitable induction system for bank and agency staff to become familiar with the crash call system
Wider context from the report “(6) It was unclear what steps had been taken by the Trust prior to 12 December 2021 to establish:
(i) the nursing qualifications of bank and/or agency staff permitted to work in the ED
(ii) whether bank and/or agency staff hold appropriate and current training in resuscitation procedures
(iii) whether a suitable induction system was in place to ensure bank and/or agency staff were familiar with the crash call system
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of audits and spot checks verifying bank and agency nurses’ familiarity with crash call procedures
Wider context from the report “(8) It is acknowledged that some additional refresher training has been carried out since this incident. There is, however, no system of audits, spot checks or dip testing to verify that bank and/or agency nurses are actually familiar with the essential procedures relating to crash calls.
” 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 Train staff conducting Patient Safety Incident Response Framework reviews, with ongoing support and updating sessions.
Verbatim wording from the response “You will be aware from previous discussions that the Trust has been a pilot site for the new Patient Safety Incident Response Framework (PSIRF) which will replace the current Serious Incident Framework. It represents a significant shift in the way the NHS responds to patient safety incidents. The PSIRF promotes a range of system-based approaches for learning from patient safety incidents and national tools and guides have been produced to support this.” Source location Response from The Leeds Teaching Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide the Emergency Department senior nursing team with a memory-capture tool to promote prompt, consistent incident recording and formalise evidence gathering.
Verbatim wording from the response “In relation to your observations regarding the chronology of events it is noted that the incident summary in the investigation report does contain an outline chronology of events. It is acknowledged that it would have been helpful if this had contained more detail in regard to the time of the doctor’s attendance and if the report had been supported by notes of discussion with relevant staff. The Trust’s Investigation Procedure includes a range of tools and templates to assist staff when conducting investigations and whilst use of these is actively encouraged, it is not mandated. In response to the specific concerns raised about the investigation of this incident, the Trust has provided the ED senior nursing team with a memory capture tool to promote prompt and consistent recording of staff involvement in incidents and to formalise the evidence gathering stage of the investigation.” Source location Response from The Leeds Teaching Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Check for new temporary staff at every shift start and complete a signed first-shift induction covering emergency and resuscitation procedures, equipment locations and reporting processes.
Verbatim wording from the response “Following the patient’s death, and during the investigation into the care provided before it, the Trust identified deficiencies in the training provided for bank and agency staff about the crash call process used by the ED teams and action has been taken to address these.” Source location Response from The Leeds Teaching Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver bespoke Patient Safety Incident Response Framework documentation sessions for Urgent Care senior staff with the Risk Management team.
Verbatim wording from the response “As a pilot site the Trust has had the opportunity to trial the new approaches and better understand the training requirements that will need to be delivered. All Trust staff charged with undertaking reviews under the new framework will receive training in how to conduct and record them. Support and advice, and regular updating sessions, will also be provided. The Urgent Care CSU has planned some bespoke sessions for their senior staff with the Trust’s Risk Management team to complete training in relation to the new investigation documentation. This will help ensure that learning from incidents is maximised and documentation is completed to a high standard.” Source location Response from The Leeds Teaching Hospital
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Additional checks for substantive staff joining the bank are considered unnecessary because mandatory training compliance is regularly reported and reviewed through their substantive roles.
Verbatim wording from the response “In this case the nurse involved in caring for the patient on 12th December 2021 was a substantive Trust employee. For these staff their substantive skill set holds true, as does their mandatory and priority training requirements. Currently there are no additional checks on completion of mandatory and priority training or DBS when substantive staff apply for the staff bank. This is because compliance with all mandatory and priority training elements is a requirement of their substantive position and is subject to regular reporting and review. As highlighted in response (2) above, the bank nurse in question was up to date with all her training requirements including resuscitation training.” Source location Response from The Leeds Teaching Hospital
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing qualification, training, induction, audit and spot-check arrangements are considered sufficient to ensure temporary ED staff understand emergency procedures.
Verbatim wording from the response “(6) In December 2021 the Trust followed a framework employment checklist for temporary workers on temporary assignments, to establish their qualifications and training prior to them starting work in the ED. This still remains the case. Staff allocated by the preferred provider to work in the EDs should only be staff with prior ED experience. Checks made cover the individual’s qualifications, skills and experience, their DBS status and completion of the Trust’s mandatory and priority training (including refresher training and updating); resuscitation training forms part of this. A CV is received for each candidate in order to verify skills and experience based on previous employment history.” Source location Response from The Leeds Teaching Hospital
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A fully independent investigation was not required because the incident was locally investigated under procedures reserving complete independence for serious incidents.
Verbatim wording from the response “(7) The investigation into the care provided to this patient was not a Serious Incident (level 3) within the terms of NHSE’s Serious Incident Framework. Within the Trust there is a grading process to decide which incidents will be fully investigated. There are three main considerations when making this decision:” Source location Response from The Leeds Teaching Hospital
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that the bank nurse lacked appropriate resuscitation training, stating that she had completed current mandatory Level 1 resuscitation training.
Verbatim wording from the response “We have considered these carefully and our response is set out below.” Source location Response from The Leeds Teaching Hospital
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that CPR was delayed for 15 minutes, stating that it began within 30 to 60 seconds of the patient being found.
Verbatim wording from the response “(1) The Trust acknowledges that there was a delay in CPR being commenced after the patient had been found in an unresponsive condition and there were discrepancies in the evidence for the inquest about timings. However, the senior sister stands by the account that she gave in court i.e., that she had been contacted at 01.15am, after the doctor had been approached, and that she attended immediately after the call to her, by which time CPR was being undertaken. In her statement for the inquest, she explained that her discussions with the relevant team members afterwards indicated that CPR had been started within 30 to 60 seconds of the patient being found. The Trust understands that it was Dr Binbay’s recollection that she had been contacted at 01.30am however this was not supported by other staff members.” Source location Response from The Leeds Teaching Hospital
Open published response
3 Dec 2021 Alexander George Theodossiadis · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 10 Absence of clear instructions on the need for timely lumbar puncture in suspected meningitis View source Failure to communicate identified falls risk to the receiving ward View source Failure to assess falls risk in confused hospital patients View source Failure to obtain sufficient information to assess appointment urgency and priority View source Absence of a clear pathway to an appropriate treatment location View source Absence of clear national leadership on lumbar puncture practice in meningitis View source Failure to provide written handover instructions or briefing notes during hospital transfer View source Absence of directions specifying action timetables for life-threatening conditions View source Insufficiently frequent refresher training for GP receptionists View source Failure to provide a nurse escort during transfer of severely unwell and confused patients View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alexander George Theodossiadis · 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
Alexander George Theodossiadis, aged 25, died in hospital on 28 January 2020 after treatment for bacterial meningitis, a fall from a hospital bed, and a resulting head injury. Concerns included difficulty obtaining a timely GP appointment and insufficient symptom assessment, inadequate hospital transfer handover and care planning, uncertainty about meningitis management, and failure to assess or communicate his risk of falling.
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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of clear instructions on the need for timely lumbar puncture in suspected meningitis
Wider context from the report “(2) Mr Theodossiadis remained in A&E for some 10 hours in total, despite the nature of his condition. Concern was expressed at the Inquest in relation to firstly, the absence of clear instructions regarding the need for a lumbar puncture within four hours of admission ; secondly, a clear pathway to an appropriate treatment location; thirdly, any directions specifying the timetable in which action was required in response to a life-threatening condition.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate identified falls risk to the receiving ward
Wider context from the report “(4) Despite spending 10 hours in A&E and displaying increasing signs of confusion he was seen to be trying to get off his hospital bed which created a risk of falls, no assessment of the falls risk was carried out. In consequence, the receiving ward J27 at St James’s University Hospital, Leeds were not forewarned of the risk of falls . He fell from his hospital bed within approximately 10 minutes of being placed in a side room on his own.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess falls risk in confused hospital patients
Wider context from the report “(4) Despite spending 10 hours in A&E and displaying increasing signs of confusion he was seen to be trying to get off his hospital bed which created a risk of falls, no assessment of the falls risk was carried out . In consequence, the receiving ward J27 at St James’s University Hospital, Leeds were not forewarned of the risk of falls. He fell from his hospital bed within approximately 10 minutes of being placed in a side room on his own.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain sufficient information to assess appointment urgency and priority
Wider context from the report “(1) The Inquest heard evidence that when Mr Theodossiadis sought an appointment with a GP, he was only able to get one in three weeks time . He did not venture any details of his symptoms. Nor, however, did the GP’s receptionist probe to obtain any information which would help to assess the urgency of the situation or the priority to be given to his request . Within six days of this telephone call, Mr Theodossiadis was irretrievably overwhelmed with a meningitis infection.
(2) GP receptionists must strike a difficult balance between respecting medical confidence and obtaining sufficient information to enable a judgement to be made in relation to access to medical help. In the case of fast-moving medical conditions such as meningitis afflicting otherwise healthy young people the Inquest heard concerns expressed that refresher training was regularly required but may not be provided with sufficient frequency to maintain vigilance at this important interface between patients and 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear pathway to an appropriate treatment location
Wider context from the report “(2) Mr Theodossiadis remained in A&E for some 10 hours in total, despite the nature of his condition. Concern was expressed at the Inquest in relation to firstly, the absence of clear instructions regarding the need for a lumbar puncture within four hours of admission; secondly, a clear pathway to an appropriate treatment location ; thirdly, any directions specifying the timetable in which action was required in response to a life-threatening condition.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of clear national leadership on lumbar puncture practice in meningitis
Wider context from the report “(3) The Inquest heard evidence that practice differs nationally on the need for a lumbar puncture in cases of meningitis . The absence of clear leadership on this issue nationally does not assist clinicians who may encounter this relatively rare, but serious condition.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide written handover instructions or briefing notes during hospital transfer
Wider context from the report “(1) Evidence was taken at the Inquest which indicated Mr Theodossiadis was moved from one hospital within the Trust to another, close to midnight on 25th January 2020. Despite being severely unwell with bacterial meningitis and in a confused state he was not accompanied by a nurse escort, nor was any written handover instruction or briefing note provided for the nurses receiving him , in breach of the prevailing Trust handover guidance .
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of directions specifying action timetables for life-threatening conditions
Wider context from the report “(2) Mr Theodossiadis remained in A&E for some 10 hours in total, despite the nature of his condition. Concern was expressed at the Inquest in relation to firstly, the absence of clear instructions regarding the need for a lumbar puncture within four hours of admission; secondly, a clear pathway to an appropriate treatment location; thirdly, any directions specifying the timetable in which action was required in response to a life-threatening condition .
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently frequent refresher training for GP receptionists
Wider context from the report “(1) The Inquest heard evidence that when Mr Theodossiadis sought an appointment with a GP, he was only able to get one in three weeks time. He did not venture any details of his symptoms. Nor, however, did the GP’s receptionist probe to obtain any information which would help to assess the urgency of the situation or the priority to be given to his request. Within six days of this telephone call, Mr Theodossiadis was irretrievably overwhelmed with a meningitis infection.
(2) GP receptionists must strike a difficult balance between respecting medical confidence and obtaining sufficient information to enable a judgement to be made in relation to access to medical help. In the case of fast-moving medical conditions such as meningitis afflicting otherwise healthy young people the Inquest heard concerns expressed that refresher training was regularly required but may not be provided with sufficient frequency to maintain vigilance at this important interface between patients and 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a nurse escort during transfer of severely unwell and confused patients
Wider context from the report “(1) Evidence was taken at the Inquest which indicated Mr Theodossiadis was moved from one hospital within the Trust to another, close to midnight on 25th January 2020. Despite being severely unwell with bacterial meningitis and in a confused state he was not accompanied by a nurse escort , nor was any written handover instruction or briefing note provided for the nurses receiving him, in breach of the prevailing Trust handover guidance.
” 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 Audit compliance with transfer-document use through a continuing rolling audit programme.
Verbatim wording from the response “The Trust is working towards 100% compliance with use of the transfer document and a rolling audit programme has been taking place over for 12 months to monitor progress. The latest audit figures are encouraging but the Trust recognises that this improvement must be sustained and therefore the process of regular audit will continue. In addition, we are” Source location 2021-0412-Response-from-St-Jamess-University-Hospital_Published
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 Embed repeated falls assessments when patients’ clinical conditions change.
Verbatim wording from the response “I can confirm that Mr Theodossiadis did have a falls risk assessment completed at 13.14 by the assessment nurse which was entered on to the ED electronic patient record Symphony. He was not deemed to be a falls risk. However when he later became more confused, his assessment should have been repeated. The senior members of the ED nursing team fully recognise the need for repeated assessments when the patient’s condition changes and are working hard to ensure that this practice is embedded within the department.” Source location 2021-0412-Response-from-St-Jamess-University-Hospital_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standard operating procedure aiming to provide lumbar puncture within one hour wherever possible.
Verbatim wording from the response “However, the Trust does recognise the potential value of an early lumbar puncture (LP) and is endeavouring to provide this diagnostic test where possible. Specifically, a lumbar puncture may allow antibiotic therapy to be rationalised, with broad spectrum treatment being replaced with more specific antibiotics. As such the Trust has developed a standard operating procedure (SOP) with the aim of carrying out a lumbar puncture within one hour wherever possible. At St James’s University Hospital during daytime hours (8am-8pm), the patient will be transferred to the Same Day Emergency Care (SDEC) unit adjacent to the Emergency Department where the LP will be carried out by a medical registrar or Advanced Practitioner.” Source location 2021-0412-Response-from-St-Jamess-University-Hospital_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor and audit daily safety and dignity checks, including identification, risk assessment and monitoring of patients at risk of falls.
Verbatim wording from the response “We are monitoring and auditing compliance regarding safety and dignity checks within the department on a daily basis. This includes identifying, risk assessing and monitoring concerns for patients who are at risk, including falls.” Source location 2021-0412-Response-from-St-Jamess-University-Hospital_Published
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 Consider how a similar lumbar-puncture arrangement could be provided at the Leeds General Infirmary site.
Verbatim wording from the response “meningitis spend much less time in the Emergency Department and can have the lumbar puncture performed by an experienced practitioner in a timely fashion. It is hoped that in due course the service will be available in the St James’s SDEC 24 hours per day. Further consideration is being given to how a similar arrangement could be provided at the LGI site.” Source location 2021-0412-Response-from-St-Jamess-University-Hospital_Published
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 Provide department-wide falls education and awareness through safety huddles and dedicated falls-awareness boards.
Verbatim wording from the response “We have improved our education and understanding of patient risk across the department regarding falls and the importance of rapid and correct assessment of patients on arrival, and the on-going assessment during their stay in ED. The risk of patient falls is continuously highlighted within the Emergency Department. Staff have regular safety huddles where vulnerable patients are discussed. In addition, dedicated ‘falls awareness’ boards have been placed throughout the departments to raise staff awareness and promote best practice. Practical initiatives that have been implemented include the provision of yellow socks for patients at risk of falls to provide a clear visual cue for staff. In addition, we now request additional Clinical Support Worker bank shifts to meet enhanced care needs of our vulnerable patients.” Source location 2021-0412-Response-from-St-Jamess-University-Hospital_Published
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 Require cross-city transfers to include a written nursing handover document recording the patient’s falls risk.
Verbatim wording from the response “For cross-city transfers we must ensure a robust handover of care between nursing staff in the ED and on the receiving ward. This may take the form of a telephone conversation but this should always be accompanied by a written handover document. Currently in the Emergency Department this takes the form of a written document that is then scanned into the electronic patient record (PPM+). The Trust is currently trialling a stand-alone electronic transfer document and it is anticipated that this will be rolled out to all areas of the Trust in due course.” Source location 2021-0412-Response-from-St-Jamess-University-Hospital_Published
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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 Seek an agreement with Yorkshire Ambulance Service not to accept transfers without a handover document recording falls risk.
Verbatim wording from the response “seeking an understanding with YAS that they will not accept patients for transfer without a handover document which clearly records the patient’s falls risk.” Source location 2021-0412-Response-from-St-Jamess-University-Hospital_Published
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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 Provide daytime lumbar puncture through the St James’s Same Day Emergency Care unit using a medical registrar or Advanced Practitioner.
Verbatim wording from the response “However, the Trust does recognise the potential value of an early lumbar puncture (LP) and is endeavouring to provide this diagnostic test where possible. Specifically, a lumbar puncture may allow antibiotic therapy to be rationalised, with broad spectrum treatment being replaced with more specific antibiotics. As such the Trust has developed a standard operating procedure (SOP) with the aim of carrying out a lumbar puncture within one hour wherever possible. At St James’s University Hospital during daytime hours (8am-8pm), the patient will be transferred to the Same Day Emergency Care (SDEC) unit adjacent to the Emergency Department where the LP will be carried out by a medical registrar or Advanced Practitioner.” Source location 2021-0412-Response-from-St-Jamess-University-Hospital_Published
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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 Record falls assessments for all Emergency Department patients and continuously audit compliance.
Verbatim wording from the response “The Trust would like to reassure the Coroner that it takes the risks of falls within the Emergency Department very seriously. All patients within the department should have a falls assessment recorded. As in the case of the handover document, compliance is continuously audited. The latest audit figures demonstrate excellent compliance with the tool, but the department recognises that this must be sustained to prevent future harm to patients.” Source location 2021-0412-Response-from-St-Jamess-University-Hospital_Published
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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 Trial a standalone electronic transfer document for cross-city transfers and work towards Trust-wide rollout.
Verbatim wording from the response “For cross-city transfers we must ensure a robust handover of care between nursing staff in the ED and on the receiving ward. This may take the form of a telephone conversation but this should always be accompanied by a written handover document. Currently in the Emergency Department this takes the form of a written document that is then scanned into the electronic patient record (PPM+). The Trust is currently trialling a stand-alone electronic transfer document and it is anticipated that this will be rolled out to all areas of the Trust in due course.” Source location 2021-0412-Response-from-St-Jamess-University-Hospital_Published
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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 Immediate antibiotics should not be delayed for lumbar puncture, which is diagnostic and may be unsafe or impracticable in some patients.
Verbatim wording from the response “1. Lumbar puncture is a diagnostic test rather than a treatment. As in the case of Mr Theodossiadis, antibiotics were administered shortly after he attended the Emergency Department in line with Trust and national guidance. In other words, treatment was commenced as soon as the team were suspicious of a serious pathology such as sepsis or meningitis. Had a lumbar puncture been carried out first and the results awaited, his life-saving treatment would have been delayed.” Source location 2021-0412-Response-from-St-Jamess-University-Hospital_Published
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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 Cross-city nurse escorts are sometimes impracticable because they remove experienced staff for over an hour and may compromise care of other patients.
Verbatim wording from the response “Given the large volumes of patients within both Emergency Departments across the city, it is sometimes not possible or practicable for a nurse to personally escort patients for a cross-city transfer. To do so would deplete the department of an experienced nurse for over an hour, with the potential to compromise care of other patients waiting for treatment. Instead, patients will be handed over to the care of the Yorkshire Ambulance Service who will facilitate safe transfer. For transfers within the same hospital, a now improving staff position means that, wherever possible, the patient will be accompanied to the new ward or clinical area by a member of the ED staff so that a direct handover can be facilitated.” Source location 2021-0412-Response-from-St-Jamess-University-Hospital_Published
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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 Yorkshire Ambulance Service facilitates safe transfer for cross-city patients instead of a Trust nurse escort.
Verbatim wording from the response “Given the large volumes of patients within both Emergency Departments across the city, it is sometimes not possible or practicable for a nurse to personally escort patients for a cross-city transfer. To do so would deplete the department of an experienced nurse for over an hour, with the potential to compromise care of other patients waiting for treatment. Instead, patients will be handed over to the care of the Yorkshire Ambulance Service who will facilitate safe transfer. For transfers within the same hospital, a now improving staff position means that, wherever possible, the patient will be accompanied to the new ward or clinical area by a member of the ED staff so that a direct handover can be facilitated.” Source location 2021-0412-Response-from-St-Jamess-University-Hospital_Published
Open published response
16 Feb 2021 Mrs Ruby Baggaley · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 7 Failure to escalate deteriorating postoperative patients to senior clinicians View source Delays in arranging prescribed traction because requisite skills are unavailable View source Inadequate postoperative monitoring of frail patients after major surgery View source Delays in providing pain relief View source Same-day cancellation of arranged surgery View source Lack of clear escalation procedures and training for deteriorating postoperative patients View source Delays in providing a Nimbus Mattress View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mrs Ruby Baggaley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Ruby Baggaley, aged 90, sustained a right distal femur fracture in a fall and died in hospital on the night of 24 January 2020 after complex surgery. Her blood pressure remained abnormally low after surgery, but escalation to senior clinicians was delayed until she was critically ill. Concerns included inadequate monitoring and failure to escalate her deteriorating condition, as well as uncertainty about whether clear escalation instructions and additional staff training had been implemented.
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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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate deteriorating postoperative patients to senior clinicians
Wider context from the report “In the period from 17:00 hours onwards her care was exclusively in the hands of a relatively junior doctor (CT2) and the nursing staff. No attempt was made to inform the surgeons or anaesthetist of the deterioration in her condition.
3) Between 16:00 hours and 20:45 hours Mrs Baggaley’s NEWS Score was 5 and remained at this level. No attempt was made to escalate her care to more senior clinicians.
It is not clear whether junior doctors and nursing staff now have clear instructions on when to escalate care in such circumstances, nor to whom.
4) By the time the surgeon was informed of the situation and travelled into the hospital around 22:00 hrs Mrs Baggaley’s condition had become critical.
It is not clear whether earlier intervention by senior clinicians would have avoided Mrs Baggaley suffering a cardiac arrest consequent upon her low blood pressure (as the Inquest was informed was the case). It is quite clear, however, that she was deprived of the opportunity to have a review by a senior clinician .
5) I am concerned that in the absence of precise information as to what, if any changes in escalation procedures have been implemented, or additional training provided to the staff involved, the potential for a comparable situation to occur again, remains.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in arranging prescribed traction because requisite skills are unavailable
Wider context from the report “6) Although it is accepted the following factors did not contribute to Mrs Baggaley’s death, they served to undermine the trust and confidence of her family in relation to the quality of care provided (particularly when contrasted with that at Leeds General Infirmary).
• A delay in providing pain relief when she arrived at Chapel Allerton Hospital on the evening of 20 January 2020.
• The delay in providing a Nimbus Mattress.
• The delay in arranging traction at Chapel Allerton Hospital, despite this having been written in her Care Plan and being in place when she was in Leeds General Infirmary. The evidence given by a family member was that she was told no-one with the requisite skill was available at the hospital.
• The cancellation of the surgery arranged for 23 January 2020 on the day it was to take place. This was lamentable not only for a frail 90 year old patient who was in pain, but was also a calamity for the efficient use of NHS resources: a theatre unused for a day; two surgeons each with a day wasted; an anaesthetist’s time wasted and one less patient treated overall.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate postoperative monitoring of frail patients after major surgery
Wider context from the report “1) On completion of the surgery Mrs Baggaley was deemed to be in a stable condition with a blood pressure of 105/49 and a NEWS Score of 3. She was transferred back to the ward at approximately 16:00 hours. In the following five hours she was located in a bed remote from the nurses’ station and was not checked frequently (as might validly be expected in the case of a frail 90 year old lady who has just undergone major surgery).
2) In the four times her blood pressure was checked between 16:00 hours and approximately 20:45 hours it was abnormally low . Her urine output was poor .
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in providing pain relief
Wider context from the report “6) Although it is accepted the following factors did not contribute to Mrs Baggaley’s death, they served to undermine the trust and confidence of her family in relation to the quality of care provided (particularly when contrasted with that at Leeds General Infirmary).
• A delay in providing pain relief when she arrived at Chapel Allerton Hospital on the evening of 20 January 2020.
• The delay in providing a Nimbus Mattress.
• The delay in arranging traction at Chapel Allerton Hospital, despite this having been written in her Care Plan and being in place when she was in Leeds General Infirmary. The evidence given by a family member was that she was told no-one with the requisite skill was available at the hospital.
• The cancellation of the surgery arranged for 23 January 2020 on the day it was to take place. This was lamentable not only for a frail 90 year old patient who was in pain, but was also a calamity for the efficient use of NHS resources: a theatre unused for a day; two surgeons each with a day wasted; an anaesthetist’s time wasted and one less patient treated overall.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Same-day cancellation of arranged surgery
Wider context from the report “6) Although it is accepted the following factors did not contribute to Mrs Baggaley’s death, they served to undermine the trust and confidence of her family in relation to the quality of care provided (particularly when contrasted with that at Leeds General Infirmary).
• A delay in providing pain relief when she arrived at Chapel Allerton Hospital on the evening of 20 January 2020.
• The delay in providing a Nimbus Mattress.
• The delay in arranging traction at Chapel Allerton Hospital, despite this having been written in her Care Plan and being in place when she was in Leeds General Infirmary. The evidence given by a family member was that she was told no-one with the requisite skill was available at the hospital.
• The cancellation of the surgery arranged for 23 January 2020 on the day it was to take place. This was lamentable not only for a frail 90 year old patient who was in pain, but was also a calamity for the efficient use of NHS resources: a theatre unused for a day; two surgeons each with a day wasted; an anaesthetist’s time wasted and one less patient treated overall.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear escalation procedures and training for deteriorating postoperative patients
Wider context from the report “In the period from 17:00 hours onwards her care was exclusively in the hands of a relatively junior doctor (CT2) and the nursing staff. No attempt was made to inform the surgeons or anaesthetist of the deterioration in her condition.
3) Between 16:00 hours and 20:45 hours Mrs Baggaley’s NEWS Score was 5 and remained at this level. No attempt was made to escalate her care to more senior clinicians.
It is not clear whether junior doctors and nursing staff now have clear instructions on when to escalate care in such circumstances, nor to whom.
4) By the time the surgeon was informed of the situation and travelled into the hospital around 22:00 hrs Mrs Baggaley’s condition had become critical.
It is not clear whether earlier intervention by senior clinicians would have avoided Mrs Baggaley suffering a cardiac arrest consequent upon her low blood pressure (as the Inquest was informed was the case). It is quite clear, however, that she was deprived of the opportunity to have a review by a senior clinician.
5) I am concerned that in the absence of precise information as to what, if any changes in escalation procedures have been implemented, or additional training provided to the staff involved, the potential for a comparable situation to occur again, remains.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in providing a Nimbus Mattress
Wider context from the report “6) Although it is accepted the following factors did not contribute to Mrs Baggaley’s death, they served to undermine the trust and confidence of her family in relation to the quality of care provided (particularly when contrasted with that at Leeds General Infirmary).
• A delay in providing pain relief when she arrived at Chapel Allerton Hospital on the evening of 20 January 2020.
• The delay in providing a Nimbus Mattress.
• The delay in arranging traction at Chapel Allerton Hospital, despite this having been written in her Care Plan and being in place when she was in Leeds General Infirmary. The evidence given by a family member was that she was told no-one with the requisite skill was available at the hospital.
• The cancellation of the surgery arranged for 23 January 2020 on the day it was to take place. This was lamentable not only for a frail 90 year old patient who was in pain, but was also a calamity for the efficient use of NHS resources: a theatre unused for a day; two surgeons each with a day wasted; an anaesthetist’s time wasted and one less patient treated overall.
” 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 Extend on-site anaesthetic and recovery-unit cover until 21:00.
Verbatim wording from the response “In addition, contact details for the operating surgeon and anaesthetist will be available to the ward staff if required. Plans are in place to extend the anaesthetic and recovery unit cover on site until 21.00. This will facilitate the post-operative reviews and management of higher risk patients. Where possible, higher risk patients will be operated on early in the day to allow an extended period of observation before the treating surgeon and anaesthetist leave the site. In addition, every effort will be made to ensure high risk patients are not operated on at the end of the working week (i.e. on Friday).” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Stop offering Chapel Allerton surgery to patients requiring traction.
Verbatim wording from the response “In the future, all elderly or frail patients being considered for transfer to Chapel Allerton Hospital will be the subject of an MDT review by a consultant team consisting of surgeons, anaesthetists and orthogeriatricians. The orthogeriatrician and anaesthetist will determine the level of risk for that individual patient. If it is determined that high-dependency care consisting of advanced cardiovascular monitoring and/or organ support will be required, the patient will remain at the LGI site and arrangements made for equipment and personnel to be transferred from Chapel Allerton. Patients requiring traction will not be offered surgery at Chapel Allerton.” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require the consultant anaesthetist to define postoperative care and NEWS thresholds for escalation to critical care outreach.
Verbatim wording from the response “On the day of surgery, the consultant anaesthetist will have the responsibility to clearly define the patient’s post-operative care, including NEWS scores that will require escalation to critical care outreach team for support out of hours.” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide rolling staff education and mandatory escalation-pathway and resuscitation training, recording junior doctors’ training on Electronic Staff Records.
Verbatim wording from the response “It is recognised that a rolling programme of staff education will be required to support the implementation of these planned changes. All staff in both the operating theatres and surgical wards will have regular training on escalation pathways and resuscitation. There will be compulsory mandatory training for the junior doctors starting their post at Chapel Allerton Hospital. This will be recorded on the Electronic Staff Records.” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Keep patients needing high-dependency care at Leeds General Infirmary and arrange transfer of required equipment and personnel.
Verbatim wording from the response “In the future, all elderly or frail patients being considered for transfer to Chapel Allerton Hospital will be the subject of an MDT review by a consultant team consisting of surgeons, anaesthetists and orthogeriatricians. The orthogeriatrician and anaesthetist will determine the level of risk for that individual patient. If it is determined that high-dependency care consisting of advanced cardiovascular monitoring and/or organ support will be required, the patient will remain at the LGI site and arrangements made for equipment and personnel to be transferred from Chapel Allerton. Patients requiring traction will not be offered surgery at Chapel Allerton.” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a dedicated policy for deteriorating patients cared for at peripheral hospital sites.
Verbatim wording from the response “During daytime working hours (08.00 -18.00) any concerns will be escalated to the consultant surgeon and anaesthetist responsible for the patient’s care. After 18.00 hours the escalation policy will be based upon clear objective assessments of the patient’s physiological status using the NEWS2 score and the Trust’s ‘Deteriorating Patient Policy’ and the ‘Transfer of Care Policy for Chapel Allerton Orthopaedic Centre’. A separate policy is being developed to specifically address the deteriorating patient being cared for in peripheral hospital sites. Plans are on-going to establish a dedicated on-call consultant rota for Chapel Allerton Hospital but in the meantime, the duty consultants at the LGI site will be available to provide advice and if necessary, review the patient.” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a dedicated on-call consultant rota for Chapel Allerton Hospital.
Verbatim wording from the response “During daytime working hours (08.00 -18.00) any concerns will be escalated to the consultant surgeon and anaesthetist responsible for the patient’s care. After 18.00 hours the escalation policy will be based upon clear objective assessments of the patient’s physiological status using the NEWS2 score and the Trust’s ‘Deteriorating Patient Policy’ and the ‘Transfer of Care Policy for Chapel Allerton Orthopaedic Centre’. A separate policy is being developed to specifically address the deteriorating patient being cared for in peripheral hospital sites. Plans are on-going to establish a dedicated on-call consultant rota for Chapel Allerton Hospital but in the meantime, the duty consultants at the LGI site will be available to provide advice and if necessary, review the patient.” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Schedule higher-risk patients early in the day to allow extended postoperative observation.
Verbatim wording from the response “In addition, contact details for the operating surgeon and anaesthetist will be available to the ward staff if required. Plans are in place to extend the anaesthetic and recovery unit cover on site until 21.00. This will facilitate the post-operative reviews and management of higher risk patients. Where possible, higher risk patients will be operated on early in the day to allow an extended period of observation before the treating surgeon and anaesthetist leave the site. In addition, every effort will be made to ensure high risk patients are not operated on at the end of the working week (i.e. on Friday).” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement defined daytime and out-of-hours escalation using consultant contacts, NEWS2 and applicable deteriorating-patient and transfer policies.
Verbatim wording from the response “During daytime working hours (08.00 -18.00) any concerns will be escalated to the consultant surgeon and anaesthetist responsible for the patient’s care. After 18.00 hours the escalation policy will be based upon clear objective assessments of the patient’s physiological status using the NEWS2 score and the Trust’s ‘Deteriorating Patient Policy’ and the ‘Transfer of Care Policy for Chapel Allerton Orthopaedic Centre’. A separate policy is being developed to specifically address the deteriorating patient being cared for in peripheral hospital sites. Plans are on-going to establish a dedicated on-call consultant rota for Chapel Allerton Hospital but in the meantime, the duty consultants at the LGI site will be available to provide advice and if necessary, review the patient.” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess patients’ skin within four hours of transfer and order appropriate pressure-relieving equipment, including specialist mattresses when already required.
Verbatim wording from the response “All patients will have a skin assessment within 4 hours of transfer and appropriate pressure relieving equipment will be ordered (this will be ordered at time of agreement to transfer if the patient is already requiring a specialist mattress).” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
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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 Chapel Allerton has necessary equipment and trained personnel for complex orthopaedic care, although some patients are unsuitable because out-of-hours cover is limited.
Verbatim wording from the response “The Trust maintains its position that Chapel Allerton Hospital has an important role in delivering care to surgical patients, including the provision of complex orthopaedic arthroplasty procedures. As an elective operating unit, Chapel Allerton has the necessary equipment and trained personnel to deliver such care. By offering operating capacity, it also frees up theatre space at Leeds General Infirmary for trauma cases. However, it is accepted that not all patients are suitable to be managed at a peripheral site where out of hours cover is limited.” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
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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 Some short-notice cancellations cannot be prevented when new safety issues outside the treating team’s control arise.
Verbatim wording from the response “With regards to the efficient use of NHS resources, I would like to reassure you that the Trust takes this very seriously and all episodes of short notice cancellation are reviewed by the management team. It must be said, however, that on rare occasions new issues outside the control of the treating team can come to light which will prevent the surgery going ahead safely. An example of this would be where a patient does not follow an instruction to stop blood thinning medications prior to the day of surgery. The Trust does strive to minimise such cancellations.” Source location 2021-0044-Response-from-St-Jamess-University-Hospital-Redacted
Open published response
18 Sep 2020 Macloud Nyeruke · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Failure to provide and verify appropriate PPE training before infectious-disease ward work View source Failure to preserve records of appropriate PPE training View source Lack of information about staff members’ medical conditions View source Failure of nursing agencies to provide hospitals with support workers’ work locations View source Failure of nursing agencies to provide hospitals with support workers’ health vulnerabilities View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Macloud Nyeruke · 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
Macloud Nyeruke was admitted to hospital on 23 November 2019 with fever, cough and confusion, and died there on 22 February 2020. He had multidrug-resistant tuberculosis and multidrug-resistant bacterial infections. The concerns included that his medical conditions were not disclosed to the Trust, uncertainty about appropriate PPE training, and risks associated with nursing agencies supplying support workers without knowledge of their health vulnerabilities or work location.
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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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide and verify appropriate PPE training before infectious-disease ward work
Wider context from the report “(2) There is scant evidence as to whether Mr Nyeruke underwent appropriate training in respect of PPE such as masks before being permitted to work on a ward involving infectious diseases . The difficulties involved (where a support worker supplied by a nursing agency is only in the hospital for a brief period) are acknowledged. Nonetheless, the risk of an adverse transmission of infection either to, or from, the staff member necessitates stringent standards being enforced , with appropriate records preserved.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to preserve records of appropriate PPE training
Wider context from the report “(2) There is scant evidence as to whether Mr Nyeruke underwent appropriate training in respect of PPE such as masks before being permitted to work on a ward involving infectious diseases. The difficulties involved (where a support worker supplied by a nursing agency is only in the hospital for a brief period) are acknowledged. Nonetheless, the risk of an adverse transmission of infection either to, or from, the staff member necessitates stringent standards being enforced, with appropriate records preserved .
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of information about staff members’ medical conditions
Wider context from the report “(1) Mr Nyeruke’s medical conditions were not made known to the Trust . In consequence, he had worked on wards where patients had infections involving multi-resistant organisms. Given his compromised immune state, this situation involved risk to both patients and Mr Nyeruke himself. In the absence of information concerning a particular staff member’s medical condition there is an increased risk of transmission of infections either to or from the staff member .
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing agencies to provide hospitals with support workers’ work locations
Wider context from the report “(3) Nursing agencies which supply support workers to hospitals without knowledge of their particular health vulnerabilities, or where they will be working , give rise to a risk that they may be adversely affected or may give rise to adverse effects on patients or colleagues .
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing agencies to provide hospitals with support workers’ health vulnerabilities
Wider context from the report “(3) Nursing agencies which supply support workers to hospitals without knowledge of their particular health vulnerabilities , or where they will be working, give rise to a risk that they may be adversely affected or may give rise to adverse effects on patients or colleagues .
” 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 Standardise shift booking notes across the Trust so high-risk areas specify that bank and agency workers must be fit tested before attending.
Verbatim wording from the response “In addition to the above, some wards are adding ‘bank notes’ to shifts that need covering specifying that the bank or agency staff member must be fit tested prior to attending the shift. Bank notes are accessible by bank and agency workers when booking the shift. We plan to standardise this approach Trust-wide so that high risk areas routinely add this to any shifts going out to bank and agency staff. To reassure ourselves that this is working we plan to audit the number of staff with the fit tested skill attached to Health Roster in the high-risk areas, including Infectious Diseases.” Source location 2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
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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 Advise vulnerable or high-risk bank and agency workers to check ward status and carry their risk assessment when potential ward moves arise.
Verbatim wording from the response “During our discussions we explored whether there was any way we could prevent high risk/vulnerable workers from viewing available shifts where a ‘general skill’ such as being fit tested or having IV drug competency is attached. We concluded that the system would not allow us to do this; however, all bank and agency staff assessed as being high risk or vulnerable have been advised to call Reed to check the status of a ward during Covid. All bank and agency staff classed as vulnerable or high risk have been advised to carry with them a copy of their risk assessment in case of any potential ward moves once their shift commences.” Source location 2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
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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 assurance that agency workers are fit tested before high-risk placements by obtaining verification, recording fit-testing status, and providing additional fit testing.
Verbatim wording from the response “In response to point 2 the Trust acknowledges that there was no documentary evidence to support Mr Nyeruke’s confirmation that he had been fit tested prior to working on J20. Following receipt of your PFD report the Trust has been in discussions with Reed with a view to obtaining more robust assurance that an agency staff member has undergone Fit testing prior to working in an area where FFP 3 masks are required.” Source location 2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit high-risk areas, including Infectious Diseases, to verify the number of staff with fit-testing status recorded in Health Roster.
Verbatim wording from the response “In addition to the above, some wards are adding ‘bank notes’ to shifts that need covering specifying that the bank or agency staff member must be fit tested prior to attending the shift. Bank notes are accessible by bank and agency workers when booking the shift. We plan to standardise this approach Trust-wide so that high risk areas routinely add this to any shifts going out to bank and agency staff. To reassure ourselves that this is working we plan to audit the number of staff with the fit tested skill attached to Health Roster in the high-risk areas, including Infectious Diseases.” Source location 2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the risk arising from agencies supplying vulnerable support workers rests with Reed agency.
Verbatim wording from the response “We have considered the contents of your report very carefully and our response is set out below. We have not responded to point 3 as we believe this matter rests with the Reed agency.” Source location 2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agency suppliers and workers are responsible for occupational-health screening and assessing placement risks before agency staff are assigned.
Verbatim wording from the response “In response to point one, our investigations have established that all the suppliers of our bank and agency staff members are responsible for ensuring the occupational health screening of their workers is completed” Source location 2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The booking system cannot prevent vulnerable or high-risk workers from viewing shifts requiring general skills such as fit testing.
Verbatim wording from the response “During our discussions we explored whether there was any way we could prevent high risk/vulnerable workers from viewing available shifts where a ‘general skill’ such as being fit tested or having IV drug competency is attached. We concluded that the system would not allow us to do this; however, all bank and agency staff assessed as being high risk or vulnerable have been advised to call Reed to check the status of a ward during Covid. All bank and agency staff classed as vulnerable or high risk have been advised to carry with them a copy of their risk assessment in case of any potential ward moves once their shift commences.” Source location 2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust cannot require staff to disclose health information because there is generally no enforceable disclosure obligation, subject to limited exceptions.
Verbatim wording from the response “in line with an agreed national framework. The results of this screening are not disclosed to the organisation where the bank or agency member of staff is placed. The Trust is therefore reliant on the agency or worker assessing the risk to the individual and other staff and patients prior to placement. It should be noted however there is no enforceable obligation on a member of staff be they bank, agency or a Trust employee to disclose information about their health. The exception to this would be where the condition poses a direct threat to the health of others, but even in these cases we are very much reliant on the member of staff’s openness despite the fact that the failure to disclose is a potential breach of Health and Safety legislation.” Source location 2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Open published response
5 Feb 2020 Adam Alexander Bojelian · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Failure to create formal written care plans for patients with complex medical needs View source Failure to maintain records of nurses’ training 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
Adam Alexander Bojelian · 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
Adam Alexander Bojelian had profound disabilities and was hospitalised for approximately 17 months before being taken to a hospice on the eve of his death on 24 March 2015. The report identified concerns about the absence of individual nurses’ training records and the lack of a formal written care plan during much of his hospital stay, despite his complex medical needs.
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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to create formal written care plans for patients with complex medical needs
Wider context from the report “(2) Formal Written Care Plans
The evidence taken at the inquest revealed that despite the complex medical needs of this child, no formal written care plan was created for the period he was in hospital, from September 2013 to January 2015 (15 months). It was assumed all the clinicians involved would glean sufficient information from a review of his notes.
The absence of a plan meant that aspects of his treatment were not exposed as being controversial (and disputed by his parents). An example of this related to hydrocortisone therapy.
In complex cases, a comprehensive care plan would provide both parents and clinicians with a basis upon which to obtain a second opinion from an independent source in the event of a dispute , as occurred repeatedly in this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain records of nurses’ training
Wider context from the report “(1) Training Records for Nurses.
The evidence revealed that in 2015, the Trust did not hold records of the training received by individual nurses . Instead, it was left to each individual nurse to maintain their own training records .
The concern arising from this is that, without accurate records, a Trust cannot be sure a particular nurse has the required skills and competence to carry out a particular task . Instances of this revealed at the Inquest was whether nurses on ward 40 at LGI had received training in relation to Bair Huggers or BiPAP ventilation equipment used in the care of critically ill children.
” Open source report
21 Oct 2019 Sharon Jamela Reeve · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 9 Lack of clarity about appropriate use of the electronic referral portal View source Lack of clarity about the issues for which specialist guidance is sought View source Lack of clarity about information required in electronic referrals View source Slow image-transfer conduit preventing review of CT and MRI images View source Failure to specify the clinical questions in specialist referrals View source Referral routing failing to provide radiologists’ reports View source Lack of firm rules requiring image review before referral responses View source Lack of a prescribed direct-access pathway to neuroradiology specialists View source Failure to clarify missing referral information before responding 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.
×
AI-generated summary
Sharon Jamela Reeve · 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 Jamela Reeve developed a persistent headache, underwent investigations and was discharged after an electronic referral to a tertiary neurosurgical unit. She was found unresponsive on 10 March 2018, underwent emergency surgery and died on 14 March 2018. The principal concerns were unclear referral pathways, incomplete and ineffective communication between hospitals, delays in specialist review, and inadequate clarity about the electronic referral system.
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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about appropriate use of the electronic referral portal
Wider context from the report “(3) Evidence was heard at the Inquest to the effect that numerous inappropriate referrals are made to the tertiary neurosurgical unit . I am concerned that this may be due to a lack of clarity at the entrance to the electronic portal so as to: -
(a) Make plain the circumstances in which it should be used – and where it is not appropriate.
(b) The information required to be included.
(c) The precise issues upon which guidance is sought.
If relatively junior clinicians are likely to be involved in the interface between DGH and tertiary specialist centres, there may well be a training component to improve the quality of information and requests submitted.
It was said that the electronic referral system in use at Leeds General Infirmary Neurosurgical Unit in March 2018 has been replaced. As the Inquest was not provided with details of the replacement system, the court was not able to consider whether the concerns outlined here have been resolved.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the issues for which specialist guidance is sought
Wider context from the report “(3) Evidence was heard at the Inquest to the effect that numerous inappropriate referrals are made to the tertiary neurosurgical unit. I am concerned that this may be due to a lack of clarity at the entrance to the electronic portal so as to: -
(a) Make plain the circumstances in which it should be used – and where it is not appropriate.
(b) The information required to be included.
(c) The precise issues upon which guidance is sought.
If relatively junior clinicians are likely to be involved in the interface between DGH and tertiary specialist centres, there may well be a training component to improve the quality of information and requests submitted.
It was said that the electronic referral system in use at Leeds General Infirmary Neurosurgical Unit in March 2018 has been replaced. As the Inquest was not provided with details of the replacement system, the court was not able to consider whether the concerns outlined here have been resolved.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about information required in electronic referrals
Wider context from the report “(3) Evidence was heard at the Inquest to the effect that numerous inappropriate referrals are made to the tertiary neurosurgical unit. I am concerned that this may be due to a lack of clarity at the entrance to the electronic portal so as to: -
(a) Make plain the circumstances in which it should be used – and where it is not appropriate.
(b) The information required to be included.
(c) The precise issues upon which guidance is sought.
If relatively junior clinicians are likely to be involved in the interface between DGH and tertiary specialist centres, there may well be a training component to improve the quality of information and requests submitted.
It was said that the electronic referral system in use at Leeds General Infirmary Neurosurgical Unit in March 2018 has been replaced. As the Inquest was not provided with details of the replacement system, the court was not able to consider whether the concerns outlined here have been resolved.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Slow image-transfer conduit preventing review of CT and MRI images
Wider context from the report “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life.
The pertinent features of the miscommunication were:
1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists).
2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed.
3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them.
4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding.
5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to specify the clinical questions in specialist referrals
Wider context from the report “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life.
The pertinent features of the miscommunication were:
1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists).
2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed.
3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them.
4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding.
5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Referral routing failing to provide radiologists’ reports
Wider context from the report “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life.
The pertinent features of the miscommunication were:
1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists . This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists).
2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed.
3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them.
4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding.
5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of firm rules requiring image review before referral responses
Wider context from the report “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life.
The pertinent features of the miscommunication were:
1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists).
2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed.
3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them.
4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding.
5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a prescribed direct-access pathway to neuroradiology specialists
Wider context from the report “(1) The two consultant radiologists at the district general hospital saw a need for a specialist opinion to assist in the interpretation of complex and abnormal CT and MRI scans. There was no clear prescribed pathway for them to obtain direct access to neuroradiologists at the tertiary centre . In consequence, an inapposite referral was made to a neurosurgical unit, which did not assist the resolution of the uncertainties regarding the correct diagnosis. My concern is that if much needed linkages between relevant groups are not appreciated and made effective, then the value of having a specialist resource could be lost in future cases, not only in the medical specialty and hospital involved here, but in many others as well.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify missing referral information before responding
Wider context from the report “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life.
The pertinent features of the miscommunication were:
1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists).
2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed.
3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them.
4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding , even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding.
5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images.
” Open source report
26 Jul 2019 Gladys May Sayles · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 3 Inadequate guidelines for the use of Aspen collars View source Inadequate training for applying and fixing collars to patients' needs View source Ineffective communications about collar fitting and patients' general care 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
Gladys May Sayles · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Gladys May Sayles was found collapsed after an unwitnessed fall at home and sustained fractures to her C2 and C3 vertebrae. She later received palliative treatment at Overgate Hospice and died there; concerns were identified about guidance, training and communication concerning the use and fitting of her hard collar.
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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate guidelines for the use of Aspen collars
Wider context from the report “• To review the existing guidelines with respect to the use of Aspen collars .
• To review training with respect to the application and fixing of the collar in order to make it bespoke to the patient's needs.
• To consider the effectiveness of the existing communications between Leeds General neurological unit, Huddersfield Royal Infirmary and the suppliers of the collar's with respect to the fitting of the collar and patients general 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate training for applying and fixing collars to patients' needs
Wider context from the report “• To review the existing guidelines with respect to the use of Aspen collars.
• To review training with respect to the application and fixing of the collar in order to make it bespoke to the patient's needs .
• To consider the effectiveness of the existing communications between Leeds General neurological unit, Huddersfield Royal Infirmary and the suppliers of the collar's with respect to the fitting of the collar and patients general 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective communications about collar fitting and patients' general care
Wider context from the report “• To review the existing guidelines with respect to the use of Aspen collars.
• To review training with respect to the application and fixing of the collar in order to make it bespoke to the patient's needs.
• To consider the effectiveness of the existing communications between Leeds General neurological unit, Huddersfield Royal Infirmary and the suppliers of the collar's with respect to the fitting of the collar and patients general care .
” Open source report
3 Oct 2018 Theresa Maria BUTTON · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 6 Failure to provide prescribed hoisting and mealtime encouragement for immobile patients View source Failure to maintain contemporaneous nursing records of food and fluid intake View source Failure to fully and effectively implement clinicians' treatment plans View source Insufficient time for clinicians and nursing staff to explain treatment decisions to family members View source Failure to ensure patients can access food in an appropriate position View source Insufficient nursing staffing levels for patients with complex needs View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Theresa Maria BUTTON · 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
Theresa Maria BUTTON underwent a liver transplant, remained in hospital for approximately 15 weeks, suffered multiple complications including a stroke, developed pneumonia, and died on 7 December 2017. Concerns included staffing levels and whether limited nursing capacity affected implementation of treatment plans, nutritional care, communication with family members, and contemporaneous record-keeping.
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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prescribed hoisting and mealtime encouragement for immobile patients
Wider context from the report “2. Evidence taken at the Inquest revealed concerns that treatment plans instituted by clinicians were not always fully or effectively implemented as the staff were often too busy, particularly at night. Example included not hoisting an immobile lady out of bed onto a chair before mealtimes' and then having time to encourage her to eat .
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain contemporaneous nursing records of food and fluid intake
Wider context from the report “5. Contemporaneous nursing records were not always maintained ; for example relating to food and fluid intake (even though nutrition was a matter of concern to the treating 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully and effectively implement clinicians' treatment plans
Wider context from the report “2. Evidence taken at the Inquest revealed concerns that treatment plans instituted by clinicians were not always fully or effectively implemented as the staff were often too busy, particularly at night . Example included not hoisting an immobile lady out of bed onto a chair before mealtimes' and then having time to encourage her to eat.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient time for clinicians and nursing staff to explain treatment decisions to family members
Wider context from the report “4. Insufficient time was available for the nursing staff and clinicians to explain treatment decisions to family members . An example given at the Inquest related to a decision to prescribe anti-depressant medication without the family being informed of any psychiatric involvement.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure patients can access food in an appropriate position
Wider context from the report “3. In this case the deceased was frail and losing weight due to not eating. A family member witnessed her food being left on her tray whilst she was laid flat and hence unable to access it with the result that it went cold and she did not eat , despite the concern relating to her nutritional condition.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing staffing levels for patients with complex needs
Wider context from the report “1. The staffing levels on Ward J83 should be reviewed , notwithstanding that they currently meet the minimum levels prescribed. The ward handles a challenging cohort of patients with liver disease who have complex needs which merit close nursing attention .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Trust-wide shortfall response document to reflect National Quality Board safe-staffing guidance.
Verbatim wording from the response “This is supported by a Trust-wide document - Actions to be taken when the numbers of Nurses and Midwives per shift falls Short of the Agreed Roster Template. This document was updated earlier in 2018 to reflect and meet the National Quality Board Guidance issued in February 2018. A copy of this is attached for your information.” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review nursing acuity, dependency and skill mix twice yearly and review roster templates against agreed staffing plans.
Verbatim wording from the response “A twice yearly ward staffing review of nursing acuity and dependency levels is undertaken, which informs changes to skill-mix required and the annual updates to the roster system. Following the July 2018 establishment and skill mix review, 102 roster templates have been reviewed to ensure they align to the current staffing level plan agreed for each ward.” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete Healthcheck auditing of ward J83 nutrition and hydration documentation and care standards.
Verbatim wording from the response “The Trust has in place an audit process referred to as the ward/department Healthcheck. This provides a systematic overview of performance across a range of key areas that influence or reflect the standards of care, patient outcomes and experience of care delivered in the Trust. The data can be viewed at organisational, CSU and ward level, providing both a local and strategic picture. A copy of the completed Healthcheck for ward J83 over a 12 months period in relation to nutrition and hydration has been included with this letter. You will note that the ward results demonstrate a very high level of compliance across the key areas identified.” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Address inconsistent nutrition and hydration record-keeping with the ward team and discuss it subsequently.
Verbatim wording from the response “Prior to, and during the course of the inquest ████████ apologised that record keeping in relation to nutrition and hydration was not to a consistently high standard. This was addressed with the ward team at the time and has been discussed subsequently.” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce daily RAG-rated nurse staffing status reporting with escalation of unmitigated ward staffing concerns.
Verbatim wording from the response “The Trust has in place a comprehensive escalation process to support CSUs in the event of staffing shortfalls and concerns. Further to a pilot in surgical services a RAG rated nurse staffing status report has been introduced for daily reporting. This daily oversight is provided by the Deputy Chief Nurse/Director of Nursing (Operations) with any unmitigated concerns regarding individual ward areas being escalated to the Chief Nurse. A weekly Red, Amber, Green (RAG) status report is provided to the quality meeting and the Executive Director meeting.” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree three staffing levels and update ward rosters to reflect current staffing plans.
Verbatim wording from the response “By way of background, following discussions with senior nursing staff, three levels of staffing for their areas has been agreed and staffing rosters have been submitted to reflect the current staffing level. The three levels are:” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue recruiting registered nurses, midwives and operating department practitioners to increase staffing capacity.
Verbatim wording from the response “The Trust continues to recruit band 5 registered nurses, midwives and operating department practitioners with 304 external registered and 5 staff starting in post since April 2018. 262 of the 304 new starters commenced in post in September and October 2018, in line with university out turns. Corresponding to our recruitment figures is a reduction in both registered and unregistered nursing and midwifery vacancies across the organisation. Registered Nurse vacancies have reduced from 14% in September 2018 to 11% in October 2018, with unregistered vacancies reducing from 6% in September to 4% in October 2018.” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Records show regular hoisting and eating encouragement; missed hoisting often followed the patient’s refusal.
Verbatim wording from the response “Mrs Button’s nursing needs, clinical treatment and support requirements were reviewed on a daily basis. Enhanced care and intentional rounding were utilised to support Mrs Button.” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Daily staffing reviews, safe-staffing systems and escalation processes are considered sufficient to manage staffing levels and patient-specific needs.
Verbatim wording from the response “Staffing levels on all of our ward areas including ward J83 are reviewed daily in accordance with safe staffing requirements together with the numbers and individual needs of our patients.” Source location 2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
30 Aug 2018 Michael John Drewell · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Failure to follow senior clinician anticoagulant-duration advice View source Failure to record senior clinician advice in electronic notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael John Drewell · 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 Drewell fell from his bike while travelling to work on 16 November 2017, sustained a hip fracture, and underwent surgery. He later suffered a cardiac arrest at home and died on 22 December 2017 from a pulmonary thromboembolism, likely a complication of the hip surgery. The concerns were that a Senior Clinician’s advice for six weeks of Tinzaparin was not followed and was not recorded in the electronic notes, resulting in a four-week prescription that ended two days before his death.
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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow senior clinician anticoagulant-duration advice
Wider context from the report “The treating Consultant advised that Mr Drewell, because of his height and weight, be given anti-coagulant Tinzaparin for six weeks rather than four weeks as was usual. He recorded his advice on the handwritten records at hospital following a ward round the day after surgery.
When the Junior Doctor came to prescribe Tinzaparin several days later he likely did not consult the handwritten notes and only prescribed four weeks Tinzaparin immediately before Mr Drewell’s discharge from hospital.
Evidence was heard that Junior Doctors would not be expected to consult the handwritten notes when prescribing drugs in accordance with NICE Guidelines.
It is of concern that the advice of a Senior Clinician was not followed and, further, that his advice was not placed upon the electronic 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record senior clinician advice in electronic notes
Wider context from the report “The treating Consultant advised that Mr Drewell, because of his height and weight, be given anti-coagulant Tinzaparin for six weeks rather than four weeks as was usual. He recorded his advice on the handwritten records at hospital following a ward round the day after surgery.
When the Junior Doctor came to prescribe Tinzaparin several days later he likely did not consult the handwritten notes and only prescribed four weeks Tinzaparin immediately before Mr Drewell’s discharge from hospital.
Evidence was heard that Junior Doctors would not be expected to consult the handwritten notes when prescribing drugs in accordance with NICE Guidelines.
It is of concern that the advice of a Senior Clinician was not followed and, further, that his advice was not placed upon the electronic notes .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record post-discharge Tinzaparin instructions on electronic drug charts and transfer them automatically to electronic discharge advice notes for eligible patients.
Verbatim wording from the response “I can reassure you that good practice is already embedded within many clinical areas throughout the Trust. For example, Elderly Medicine patients with pelvic fractures who are being discharged to care in the community (CIC) beds have Tinzaparin continued until they are weight bearing after discharge. An instruction to this effect is added to the electronic drug chart and this information is then pulled through automatically to the EDAN. In addition, our pharmacists will also add electronic notes regarding discharge medication advice following multi-disciplinary team meetings with treating clinicians.” Source location 2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add electronic notes recording discharge medication advice after multidisciplinary team meetings with treating clinicians.
Verbatim wording from the response “I can reassure you that good practice is already embedded within many clinical areas throughout the Trust. For example, Elderly Medicine patients with pelvic fractures who are being discharged to care in the community (CIC) beds have Tinzaparin continued until they are weight bearing after discharge. An instruction to this effect is added to the electronic drug chart and this information is then pulled through automatically to the EDAN. In addition, our pharmacists will also add electronic notes regarding discharge medication advice following multi-disciplinary team meetings with treating clinicians.” Source location 2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Comprehensively reviewing the entire medical record before electronic discharge prescribing is considered impractical for junior doctors.
Verbatim wording from the response “In your Regulation 28 Report you highlight the fact that the junior doctor did not consult the hand-written medical records before prescribing the anticoagulant medication. I am sure that you will agree that it is impractical for junior doctors to comprehensively review the medical record in its entirety when completing the electronic discharge advice note (EDAN) and prescription. It is therefore imperative that if individual clinicians decide to prescribe ‘off protocol’ they either action this themselves personally, or leave clear unambiguous instructions within the electronic record. This can be done in two ways; either the eMeds electronic prescribing chart can be annotated or the EDAN can be pre-populated with specific discharge advice.” Source location 2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust determined that Tinzaparin was correctly prescribed under NICE guidance, and a longer course could not be shown to have prevented death.
Verbatim wording from the response “At the inquest it was accepted that it was not possible to say that the ending of the prescription more than minimally contributed to his death. The Trust provided a root cause analysis summary that concluded that the correct dose of Tinzaparin had been prescribed for a gentleman of Mr Drewell’s height and weight and that there had been no lapses in care. Tinzaparin was prescribed at discharge according to NICE guidance. The trust has therefore determined that, notwithstanding the request by an individual consultant, Tinzaparin was correctly prescribed for Mr Drewell and it is not possible to say that a longer course of the anticoagulant would have prevented his death.” Source location 2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
10 Aug 2016 Thomas George Jordan · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 4 Unavailability of discharge correspondence to prison healthcare staff View source Failure to review discharge correspondence by prison healthcare staff View source Breakdown in communication between hospital and prison at discharge View source Failure to discontinue prescribed medication when requested by hospital clinicians View source See 1 more concern
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
Thomas George Jordan · 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
Thomas George Jordan, a remand prisoner at Her Majesty’s Prison, Leeds, became unwell with cardiac symptoms and was admitted to hospital on 6 August 2015. His condition deteriorated, and he died following cardiac arrest at 1955 hours that day; the inquest recorded natural causes. The concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication when he was discharged from hospital, although the report stated there was no evidence that the drug error materially caused or contributed to his death.
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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of discharge correspondence to prison healthcare staff
Wider context from the report “(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued.
(2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged.
(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them.
(4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review discharge correspondence by prison healthcare staff
Wider context from the report “(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued.
(2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged.
(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them .
(4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Breakdown in communication between hospital and prison at discharge
Wider context from the report “(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued.
(2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged .
(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them.
(4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discontinue prescribed medication when requested by hospital clinicians
Wider context from the report “(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued .
(2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged.
(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them.
(4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death.
” Open source report
10 Aug 2016 Thomas George Jordan · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 4 Breakdown in hospital-to-prison discharge communication View source Failure to discontinue medication when directed by hospital clinicians View source Delayed availability of discharge correspondence to prison healthcare staff View source Failure by prison healthcare staff to review discharge correspondence View source See 1 more concern
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
Thomas George Jordan · 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
Thomas George Jordan, a remand prisoner at Her Majesty’s Prison, Leeds, became unwell with cardiac and other medical problems and died in hospital after suffering cardiac arrest on 6 August 2015. Concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication between the hospital and prison, although the report stated there was no evidence that the drug error materially caused or contributed to his death.
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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Breakdown in hospital-to-prison discharge communication
Wider context from the report “(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued.
(2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged .
(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them.
(4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death.
(5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect.
(6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discontinue medication when directed by hospital clinicians
Wider context from the report “(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued .
(2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged.
(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them.
(4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death.
(5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect.
(6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delayed availability of discharge correspondence to prison healthcare staff
Wider context from the report “(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued.
(2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged.
(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them.
(4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death.
(5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect.
(6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by prison healthcare staff to review discharge correspondence
Wider context from the report “(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued.
(2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged.
(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them .
(4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death.
(5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect.
(6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose.
” Open source report
3 Mar 2016 Adam RICE · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Failure to maintain a trained and experienced reserve of custody staff for rapid deployment View source Failure to communicate outstanding investigations or treatment to police after a patient self-discharges View source Failure to recruit suitably capable custody staff View source Inadequate custody staffing levels during periods of high demand View source Lack of comprehensive knowledge of custody law and procedures among custody staff View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Adam RICE · 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
Adam RICE was taken to hospital after being found asleep in a skateboard park, later self-discharged without a CT head scan, and was subsequently detained at a police station after being arrested. He exhibited signs of alcohol withdrawal, collapsed and died in his cell on 12 May 2014. The report identified concerns about communication between hospital staff and police, custody staffing and training, welfare checks, observation levels, handovers and monitoring practices.
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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a trained and experienced reserve of custody staff for rapid deployment
Wider context from the report “3b To ensure that they have a bank of staff who might ordinarily be engaged in other duties but who are trained and have experience in Custody work who can be drafted in at short notice during such periods of high demand when it becomes obvious that the existing staff cannot cope with the demands being placed upon them .
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate outstanding investigations or treatment to police after a patient self-discharges
Wider context from the report “1. When a patient self-discharges against medical advice and it is known or it is highly likely that the Police will immediately thereafter become involved and it can be foreseen that the patient will be taken into Custody .
2. Then the Clinician(s) involved should inform the Police that the person has self-discharged against advice and should give brief details of any desired and outstanding investigations or treatment (eg. Reference to a possible head injury would suffice and the desire to carry out a CT head scan). This I suggest would not breach patient confidentiality.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recruit suitably capable custody staff
Wider context from the report “2. That West Yorkshire Police only recruit Custody staff of the highest calibre to carry out this vital role involving some of the most vulnerable members of society.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate custody staffing levels during periods of high demand
Wider context from the report “3a To ensure that there are adequate staffing levels of all ranks and grades to fulfil this vital role particularly during periods of high demand when it is known that Custody facilities will be extremely busy and in particular on Fridays, Saturdays and Sundays.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive knowledge of custody law and procedures among custody staff
Wider context from the report “1. To ensure that Custody staff to which I mean Police Officers of all ranks, Civilian Detention Officers and Nursing staff have a full and comprehensive knowledge of the Police and Criminal Evidence Act and the relevant Codes of Practice and the relevant provisions of the College of Policing Authorised Professional Practice Provisions in respect of Detention and Custody and Custody Management Planning .
” Open source report
×
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 Existing arrangements provide relevant medical-information handovers when patients transfer to recognised facilities with trained medical or nursing staff.
Verbatim wording from the response “iii) Our Emergency Department staff would like to reassure you that there are already arrangements in place for a handover of relevant medical information when patients are discharged from the Emergency Department. When a patient leaves the department for their own home, their GP will receive a discharge summary and the patient will normally be given advice in the presence of their next of kin as to features which warrant re-attendance. Similarly, when a patient is transferred to another hospital, relevant details will accompany the patient to the new healthcare provider and a formal handover of care will take place. The same principle applies where a patient is being transferred to a facility, such as a Police Custody Suite that is recognised to have trained medical or nursing staff.” Source location Adam-Rice-Response_Redacted
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 Routine police contact after self-discharge is considered infeasible, unreasonable, time-consuming and likely to breach confidentiality unjustifiably.
Verbatim wording from the response “iv) The reality of a current day Emergency Department is that many patients take their own discharge every week. Many such patients will be known to the Police. We do not believe it feasible or reasonable to expect a healthcare practitioner to make a judgement as to whether that patient is likely to be arrested soon after discharge against medical advice. We believe that routinely contacting the Police in these circumstances would take a significant amount of” Source location Adam-Rice-Response_Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinicians could not identify a lawful public-interest justification to disclose medical information to police without the patient’s consent.
Verbatim wording from the response “i) The General Medical Council set out in their 2009 guidance (“Confidentiality”) at Paragraph 36 the circumstances where a disclosure without patient consent can be made in the public interest. Essentially this is confined to a situation where there is a need to protect individuals from serious harm, such as serious communicable diseases or serious crime. As you know, the GMC takes the view that there is a clear public good from having a confidential medical service and quite rightly doctors who break patient confidentiality put themselves at risk of serious censure. After extensive multi-disciplinary discussion on this matter, we have been unable to identify either an indication for disclosing information about Mr Rice’s medical assessment or a justification in this case for such disclosure without the necessary permissions.” Source location Adam-Rice-Response_Redacted
Open published response
Concerns raised 9 Failure of receiving teams to identify and fill gaps in referral information View source Absence of procedures for MDT meetings to proactively follow up inadequately completed referral forms View source Failure to ensure identification and electronic transmission of recent radiological evidence View source Failure to identify and transfer key clinical information to receiving teams View source Failure to ensure identification and transfer of key referral information View source Lack of procedures to proactively obtain information to complete gaps in clinical history View source Inadequate training of junior doctors completing referral forms View source Lack of understanding of key information required in referrals View source Ineffective training for junior doctors completing referral forms View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dorothy Cooper · 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
Dorothy Cooper underwent elective surgery on 29 September 2014, after which complications included splenic injury, liver ischaemia and infarction, and poor nutritional status. She later developed overwhelming sepsis and died in hospital on 6 January 2015. The principal concerns were incomplete information in a referral to the receiving team and inadequate procedures for identifying and following up gaps in the clinical history.
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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of receiving teams to identify and fill gaps in referral information
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this .
My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled , then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. Inadequate training of junior doctors who complete referral forms.
2. A lack of understanding as to what key information is required in referrals of this nature.
3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of procedures for MDT meetings to proactively follow up inadequately completed referral forms
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospital Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture would have pointed more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in terms of clear clinical parameters but failed to proactively pursue this.
My concern is that it is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. The absence of clear procedures for those in MDT meetings to proactively follow up inadequately completed referral forms .
2. Lack of procedures to proactively obtain information to complete gaps in clinical history
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure identification and electronic transmission of recent radiological evidence
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this.
My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. Inadequate training of junior doctors who complete referral forms.
2. A lack of understanding as to what key information is required in referrals of this nature.
3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and transfer key clinical information to receiving teams
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team . The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history . It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this.
My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team , and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. Inadequate training of junior doctors who complete referral forms.
2. A lack of understanding as to what key information is required in referrals of this nature.
3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure identification and transfer of key referral information
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospital Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture would have pointed more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in terms of clear clinical parameters but failed to proactively pursue this.
My concern is that it is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team , and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. The absence of clear procedures for those in MDT meetings to proactively follow up inadequately completed referral forms.
2. Lack of procedures to proactively obtain information to complete gaps in clinical history
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures to proactively obtain information to complete gaps in clinical history
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospital Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture would have pointed more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in terms of clear clinical parameters but failed to proactively pursue this.
My concern is that it is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. The absence of clear procedures for those in MDT meetings to proactively follow up inadequately completed referral forms.
2. Lack of procedures to proactively obtain information to complete gaps in clinical history
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of junior doctors completing referral forms
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this.
My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. Inadequate training of junior doctors who complete referral forms.
2. A lack of understanding as to what key information is required in referrals of this nature.
3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of key information required in referrals
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this.
My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. Inadequate training of junior doctors who complete referral forms.
2. A lack of understanding as to what key information is required in referrals of this nature.
3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective training for junior doctors completing referral forms
Wider context from the report “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospital Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture would have pointed more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in terms of clear clinical parameters but failed to proactively pursue this.
My concern is that it is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.
Matters of concern in summary are :
1. The absence of clear procedures for those in MDT meetings to proactively follow up inadequately completed referral forms.
2. Lack of procedures to proactively obtain information to complete gaps in clinical history
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recirculate the updated pathway and highlight the need to complete referral forms fully and accurately.
Verbatim wording from the response “To reiterate the importance of submitting relevant clinical information, the Hepatobiliary MDT Co-ordinator has re-circulated the pathway document that was updated in October 2014 and highlighted the need for completion of the referral form as fully and accurately as possible.” Source location 2015-0412-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand the MDT meeting allocation from 8–11am to 8am–12:30pm.
Verbatim wording from the response “Recently the MDT time allocation has been expanded from 8-11am to 8-12.30pm. On average 55-60 cases are reviewed. The demand on the service is huge and increasing. The staff in the MDT do their reasonable best to obtain the information they need. The MDT is supported by an MDT Co-ordinator/Data Manager who collates the cases for review and records the outcomes of the decisions. There is an increasing tendency to determine a management plan from a provisional or ‘working’ diagnosis made on the basis of radiological and blood tests but this must be regarded as provisional and ultimately a tissue diagnosis from a biopsy or complete resection of the abnormality is required to confirm the impression, or alternatively the patient is monitored to assess the response to empirical treatment, for example with antibiotics” Source location 2015-0412-Response2
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The lack of clinical details did not influence the final diagnosis, treatment or outcome.
Verbatim wording from the response “The MDT has noted that you have raised concerns that they reviewed Mrs Cooper’s case at their MDT meeting without adequate clinical details. They wish to highlight the fact that they did make attempts to obtain the details by way of correspondence with Mid-Yorkshire NHS Trust (Pinderfields General Hospital). The team is clear however that the lack of details did not influence the final diagnosis, treatment or outcome.” Source location 2015-0412-Response2
Open published response
6 Mar 2015 Connor Adrian Turner · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Failure to initially supervise parents and carers performing oxygen-supply transfers until competent View source Failure to verify users' competence with oxygen apparatus before hospital departure View source Failure to independently check oxygen apparatus function before hospital departure View source Lack of a system for instructing and training parents and carers to transfer oxygen supplies to portable cylinders View source Failure to record oxygen-apparatus readiness and user competence checks in case notes View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Implement a risk assessment for parent-supervised off-ward trips, documenting training, competence, responsibilities, permitted absence, and checks before each trip.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2015. View source
Action
Implement a staff-parent oxygen-therapy risk assessment with education on prescribed use, equipment operation, flow-rate control, and fire, tubing, and product-related hazards.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2015. View source
Action
Implement an oxygen-therapy ward-exit checklist verifying clinical stability, cylinder operation, parental equipment competence, cylinder duration, and saturation-monitor readiness.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2015. View source
×
AI-generated summary
Connor Adrian Turner · 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
Connor Adrian Turner, who had cystic fibrosis, congenital heart disease and required oxygen, stopped breathing while shopping with his parents after the oxygen cylinder valve was found to be off. His death was unascertained, with the inquest stating that lack of oxygen was a contributory factor. The concerns identified included the absence of a system to train and supervise parents or carers in transferring and checking portable oxygen equipment before leaving 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to initially supervise parents and carers performing oxygen-supply transfers until competent
Wider context from the report “(1) There is no system in place for nursing staff to instruct and train parents and carers in the transfer of the oxygen supply from the main supply to a portable oxygen cylinder.
(2) That parents and carers should be initially supervised in forming this task until they are deemed to be competent to do so .
(3) That when a transfer has been made in preparation for the patient leaving the hospital, albeit temporarily, the patient should not be allowed to leave until an independent check has been made and all concerned are satisfied that the apparatus is functioning correctly and that those taking the patient out of hospital are competent to use the apparatus and that the appropriate reference to this should be made in the case 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to verify users' competence with oxygen apparatus before hospital departure
Wider context from the report “(1) There is no system in place for nursing staff to instruct and train parents and carers in the transfer of the oxygen supply from the main supply to a portable oxygen cylinder.
(2) That parents and carers should be initially supervised in forming this task until they are deemed to be competent to do so.
(3) That when a transfer has been made in preparation for the patient leaving the hospital, albeit temporarily, the patient should not be allowed to leave until an independent check has been made and all concerned are satisfied that the apparatus is functioning correctly and that those taking the patient out of hospital are competent to use the apparatus and that the appropriate reference to this should be made in the case 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to independently check oxygen apparatus function before hospital departure
Wider context from the report “(1) There is no system in place for nursing staff to instruct and train parents and carers in the transfer of the oxygen supply from the main supply to a portable oxygen cylinder.
(2) That parents and carers should be initially supervised in forming this task until they are deemed to be competent to do so.
(3) That when a transfer has been made in preparation for the patient leaving the hospital, albeit temporarily, the patient should not be allowed to leave until an independent check has been made and all concerned are satisfied that the apparatus is functioning correctly and that those taking the patient out of hospital are competent to use the apparatus and that the appropriate reference to this should be made in the case 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for instructing and training parents and carers to transfer oxygen supplies to portable cylinders
Wider context from the report “(1) There is no system in place for nursing staff to instruct and train parents and carers in the transfer of the oxygen supply from the main supply to a portable oxygen cylinder .
(2) That parents and carers should be initially supervised in forming this task until they are deemed to be competent to do so.
(3) That when a transfer has been made in preparation for the patient leaving the hospital, albeit temporarily, the patient should not be allowed to leave until an independent check has been made and all concerned are satisfied that the apparatus is functioning correctly and that those taking the patient out of hospital are competent to use the apparatus and that the appropriate reference to this should be made in the case 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record oxygen-apparatus readiness and user competence checks in case notes
Wider context from the report “(1) There is no system in place for nursing staff to instruct and train parents and carers in the transfer of the oxygen supply from the main supply to a portable oxygen cylinder.
(2) That parents and carers should be initially supervised in forming this task until they are deemed to be competent to do so.
(3) That when a transfer has been made in preparation for the patient leaving the hospital, albeit temporarily, the patient should not be allowed to leave until an independent check has been made and all concerned are satisfied that the apparatus is functioning correctly and that those taking the patient out of hospital are competent to use the apparatus and that the appropriate reference to this should be made in the case notes .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a risk assessment for parent-supervised off-ward trips, documenting training, competence, responsibilities, permitted absence, and checks before each trip.
Verbatim wording from the response “Evidence was given at the inquest of the actions that have been implemented following the publication of the investigation report. In summary, the clinical team has devised and implemented three documents which are completed by staff and parents. These are:” Source location 2015-0082-Response-by-Leeds-Teaching-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a staff-parent oxygen-therapy risk assessment with education on prescribed use, equipment operation, flow-rate control, and fire, tubing, and product-related hazards.
Verbatim wording from the response “Evidence was given at the inquest of the actions that have been implemented following the publication of the investigation report. In summary, the clinical team has devised and implemented three documents which are completed by staff and parents. These are:” Source location 2015-0082-Response-by-Leeds-Teaching-Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an oxygen-therapy ward-exit checklist verifying clinical stability, cylinder operation, parental equipment competence, cylinder duration, and saturation-monitor readiness.
Verbatim wording from the response “Evidence was given at the inquest of the actions that have been implemented following the publication of the investigation report. In summary, the clinical team has devised and implemented three documents which are completed by staff and parents. These are:” Source location 2015-0082-Response-by-Leeds-Teaching-Hospitals
Open published response
20 Feb 2015 Lexie Louise Harrison · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 9 Lack of local policy and/or guidelines for paediatric endoscopic banding of oesophageal varices View source Failure to standardise Consultant practice for paediatric endoscopic banding of oesophageal varices View source Lack of defined Consultant competency and supervision criteria for the procedure View source Lack of standardised post-endoscopy care requirements View source Lack of a defined pre-procedure assessment process for banding programme patients View source Lack of defined patient suitability criteria for banding programmes View source Lack of defined criteria for which varices should undergo banding View source Lack of defined assessment and management steps for variceal bleeding View source Lack of precise definitions of oesophageal varix grades View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lexie Louise Harrison · 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
Lexie Louise Harrison, who had Infantile Refsum Disease, underwent an unsuccessful attempt to band an oesophageal varix on 30 May 2013, which caused trauma and extensive bleeding. Her condition deteriorated and she died at home on 18 June 2013; the medical cause of death was recorded as liver failure and Infantile Refsum Disease. The concerns included the absence of relevant policies or guidelines at two trusts and a lack of standardisation in practice, including decisions about banding, assessment, post-endoscopy care, management of bleeding, and consultant competence.
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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of local policy and/or guidelines for paediatric endoscopic banding of oesophageal varices
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to standardise Consultant practice for paediatric endoscopic banding of oesophageal varices
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure , by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of defined Consultant competency and supervision criteria for the procedure
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised post-endoscopy care requirements
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a defined pre-procedure assessment process for banding programme patients
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of defined patient suitability criteria for banding programmes
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of defined criteria for which varices should undergo banding
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of defined assessment and management steps for variceal bleeding
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of precise definitions of oesophageal varix grades
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share Leeds emergency variceal-management guidelines with referring trusts.
Verbatim wording from the response “These guidelines are very similar to those used in both London and Birmingham and we have shared the Leeds guidelines with our referring Trusts including Sheffield Children’s Hospital.” Source location 2015-0070-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in the international prophylactic-banding study, recruiting patients and recording procedure outcomes in a database.
Verbatim wording from the response “Currently the three UK Paediatric Liver Centres have agreed to take part in an International study which asks the Centres to recruit patients following a surveillance endoscopy to each Centre’s normal management i.e. no prophylactic banding; prophylactic banding in certain age groups; and prophylactic banding in most children. The centres will be required to keep a database of the outcomes of these procedures to get a better understanding of the efficacy and safety of prophylactic banding in children. This is not a randomised study but is deemed to be the only way to recruit large numbers of children.” Source location 2015-0070-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss standardisation of oesophageal-variceal banding practices through the UK Paediatric Liver Steering Group.
Verbatim wording from the response “The Leeds team have advised me that the standardisation of practices is to be discussed at the UK Paediatric Liver Steering Group which includes representatives from the three UK Paediatric Liver Centres and a representative of the Paediatric Gastroenterology Centres with an interest in hepatology.” Source location 2015-0070-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the international study’s agreed variceal-grading scale and endoscopy photographs to standardise grading across centres.
Verbatim wording from the response “In response to part (a), (b), (c) and (d) the definitions of oesophageal variceal grading is always subjective; hence there is a variety of grading scales in both adult and paediatric practice. However, there will be an agreed grading scale for the International study referred to above and this will be shared with all Centres. Photographs will be taken at endoscopy to standardise the grading. The results of this study should help clinical teams to make recommendations about who should be put forward for prophylactic banding; which grades of varices should be subject to prophylactic banding; and what the risks are of inducing bleeding by prophylactic banding.” Source location 2015-0070-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current guidelines are considered sufficient for post-operative care and management of bleeding varices, including after prophylactic banding.
Verbatim wording from the response “In relation to parts (e) and (f), post-operative care is the same whether the patient undergoes prophylactic banding or banding after bleeding, and the Leeds team will follow their current guidelines as for management of bleeding varices.” Source location 2015-0070-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prophylactic banding in younger children is not offered because the evidence is predominantly adult and further evidence is awaited.
Verbatim wording from the response “In Leeds, following considerable deliberation of the evidence available, the clinical team concluded that they should only offer prophylactic banding to children over 10 years of age who are found to have large varices. They felt that the evidence base is very much adult literature and therefore they can justify applying that to children over 10 years of age but should await further evidence before applying this management to younger children. In King's College Hospital, London, they do not undertake prophylactic banding at all in children.” Source location 2015-0070-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assessment of competency in interventional endoscopy is being addressed nationally within the Royal College specialty advisor committee.
Verbatim wording from the response “The assessment of competency in interventional endoscopy is under discussion at a national level within the Paediatric Gastroenterology and Hepatology College Specialty Advisor Committee, within the Royal College of Paediatrics and Child Health.” Source location 2015-0070-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Standardisation of consultant practices is to be discussed by the UK Paediatric Liver Steering Group rather than undertaken solely by the Trust.
Verbatim wording from the response “The Leeds team have advised me that the standardisation of practices is to be discussed at the UK Paediatric Liver Steering Group which includes representatives from the three UK Paediatric Liver Centres and a representative of the Paediatric Gastroenterology Centres with an interest in hepatology.” Source location 2015-0070-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Open published response
9 Jan 2015 Pauline Taylor · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Lack of a designated clinical case manager for complex and uncertain cases View source Insufficient precision of the surgical term ‘nephroureterectomy’ View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Pauline Taylor · 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
Pauline Taylor underwent surgery in November 2010 intended to remove her right kidney and ureter, but only approximately 5 cm of the ureter was removed. Persistent pain led to the discovery of an inoperable tumour in the remaining ureter, followed by metastases in the liver and lungs; she died at home on 12 May 2012. Concerns included ambiguity in the term “nephroureterectomy” and the absence of a designated person to coordinate care in this complex case.
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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a designated clinical case manager for complex and uncertain cases
Wider context from the report “(2) In this complex case, no firm diagnosis had been established. There was no one person in the clinical team whose role was to monitor progress, liaise with the patient and the various clinicians involved and ensure her significant ongoing problems were heard and heeded. Evidence was taken at the Inquest from an expert witness who described the benefits of a ‘case manager’ role, used in other NHS Trusts in cases characterised by uncertainty and complexity.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient precision of the surgical term ‘nephroureterectomy’
Wider context from the report “(1) The surgical term ‘nephroureterectomy’ appears to lack sufficient precision to avoid any possibility of misunderstandings between clinicians as to the extent of the procedure to be performed. One surgeon gave evidence at the Inquest that the term involved the removal of a kidney and the entire ureter. Another surgeon, however, gave evidence that the term was sufficiently broad to allow the removal of only a portion of the ureter. By the time the difference in their understanding of this term of art became clear the deceased had an inoperable tumour located in the remaining portion of the ureter.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Emphasise the definition of nephroureterectomy to urological surgeons, anaesthetists and theatre staff and include it in staff induction information.
Verbatim wording from the response “Following receipt of your Report, we sought confirmation and advice from the British Association of Urological Surgeons on the term. They confirmed that the term nephroureterectomy means the removal of the kidney with the whole ureter. They pointed out that there may be circumstances where it is not possible to remove the whole ureter. In this case the finding should be clearly recorded in the notes and follow up arrangements made.” Source location 2015-0008-Response-by-Leeds-Teaching-Hospital
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 Fill clinical nurse specialist posts to support cancer care coordination.
Verbatim wording from the response “We established that in other organisations the case manager role is frequently undertaken by Clinical Nurse Specialists. We confirmed that their processes for assigning nurse specialists to coordinate care were the same that we use in our cancer centre. At the time of Mrs Taylor’s case a number of these posts were being recruited to. I can confirm that these posts are now filled and any patient attending clinics with a possible diagnosis of cancer is assigned a clinical nurse specialist to follow their case and act as a point for communication.” Source location 2015-0008-Response-by-Leeds-Teaching-Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign a clinical nurse specialist to follow the case and provide communication for every patient attending clinics with a possible cancer diagnosis.
Verbatim wording from the response “We established that in other organisations the case manager role is frequently undertaken by Clinical Nurse Specialists. We confirmed that their processes for assigning nurse specialists to coordinate care were the same that we use in our cancer centre. At the time of Mrs Taylor’s case a number of these posts were being recruited to. I can confirm that these posts are now filled and any patient attending clinics with a possible diagnosis of cancer is assigned a clinical nurse specialist to follow their case and act as a point for communication.” Source location 2015-0008-Response-by-Leeds-Teaching-Hospital
Open published response
30 Apr 2014 Mary WANYA · Prevention of Future Deaths report West Yorkshire (East)
View report summary
Concerns raised 5 Failure of investigation reports to address relevant clinical issues and delays View source Failure to ensure investigation authors have appropriate clinical knowledge, experience and qualifications View source Failure to provide prompt assessment, diagnosis and treatment of mental illness View source Delays in obtaining urgent psychiatric assessments View source Failure to promptly rule out physical illness contributing to mental disturbance 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
Mary WANYA · 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 Wanya died after falling through a hospital window on 1 November 2011 while in an acutely confused and agitated state. The window restrictor was defective, allowing the window to be fully opened. Concerns included delays in psychiatric assessment, the assessment and treatment of mental illness on the Medical Admissions Unit, her earlier diagnosis and discharge, and the inadequacy of the Trust’s investigation report.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of investigation reports to address relevant clinical issues and delays
Wider context from the report “(2) Regarding the Trusts Level 3 Investigation Report prepared by ████████ Head of Health and Safety dated 8th February 2012.
I regard this as being an inadequate and unhelpful Report, which only concentrated on the defective windows, which although a relevant issue, this Report did not address the serious issues in respect of Mary Wanya’s misdiagnosis and her inappropriate discharge from Ward 26 on 30th October 2011 . The Report did not address the delays in ruling out physical illness outlined herein and the subsequent delays in obtaining psychiatric assessment .
I therefore recommend that the Trust should review it’s procedures for the instigation of such Reports and should ensure that the Lead Investigator and the author of such Reports has appropriate knowledge, experience and qualifications to address the relevant issues. It is clear to me that a person from a Health and Safety background, such as ████████, did not have the appropriate knowledge, experience and qualifications to assess medical and clinical issues, which was clearly part of the Root cause of this enquiry
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure investigation authors have appropriate clinical knowledge, experience and qualifications
Wider context from the report “(2) Regarding the Trusts Level 3 Investigation Report prepared by ████████ Head of Health and Safety dated 8th February 2012.
I regard this as being an inadequate and unhelpful Report, which only concentrated on the defective windows, which although a relevant issue, this Report did not address the serious issues in respect of Mary Wanya’s misdiagnosis and her inappropriate discharge from Ward 26 on 30th October 2011. The Report did not address the delays in ruling out physical illness outlined herein and the subsequent delays in obtaining psychiatric assessment.
I therefore recommend that the Trust should review it’s procedures for the instigation of such Reports and should ensure that the Lead Investigator and the author of such Reports has appropriate knowledge, experience and qualifications to address the relevant issues . It is clear to me that a person from a Health and Safety background, such as ████████, did not have the appropriate knowledge, experience and qualifications to assess medical and clinical issues , which was clearly part of the Root cause of this enquiry
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prompt assessment, diagnosis and treatment of mental illness
Wider context from the report “1. (i) There was a considerable delay of over 60 hours before a psychiatrist attended St James’s University Hospital to assess Mary Wanya. In fact the psychiatrist arrived 5 minutes after her fall had occurred and hence she never received a psychiatric assessment.
(ii) The Trust should review the system for obtaining urgent psychiatric assessments, particularly out of hours, with a view to speeding up and providing a more efficient service.
(iii) In view of the size and scale of the St James’s University site the Trust should consider having an on site resident psychiatrist to avoid the obvious delay in bringing psychiatrists from St Mary’s Hospital, which is some distance away and will exacerbate delay.
(iv) The Trust should consider making arrangements with the Mental Health Trust responsible for the Becklin Centre so that the Becklin Centre staff should be involved with such patients, particularly out of hours, to avoid delay and to provide earlier diagnosis and treatment. Had Mrs Wanya been transferred to the Becklin Centre and been psychiatrically assessed and her treatment had commenced much earlier, it is likely that this death could have been avoided.
(v) There is an inferior system for the assessment and treatment of patients on the Medical Admissions Unit of patients suffering from mental illness in comparison with those who are physically ill . The Trust should therefore review this urgently and ensure that the systems are developed to provide for a faster system to rule out physical illness that might cause or contribute to mental disturbance and when this has been achieved to provide a prompt assessment, diagnosis and treatment for such patients in respect of their obvious mental illness .
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining urgent psychiatric assessments
Wider context from the report “1. (i) There was a considerable delay of over 60 hours before a psychiatrist attended St James’s University Hospital to assess Mary Wanya . In fact the psychiatrist arrived 5 minutes after her fall had occurred and hence she never received a psychiatric assessment .
(ii) The Trust should review the system for obtaining urgent psychiatric assessments, particularly out of hours, with a view to speeding up and providing a more efficient service.
(iii) In view of the size and scale of the St James’s University site the Trust should consider having an on site resident psychiatrist to avoid the obvious delay in bringing psychiatrists from St Mary’s Hospital, which is some distance away and will exacerbate delay.
(iv) The Trust should consider making arrangements with the Mental Health Trust responsible for the Becklin Centre so that the Becklin Centre staff should be involved with such patients, particularly out of hours, to avoid delay and to provide earlier diagnosis and treatment. Had Mrs Wanya been transferred to the Becklin Centre and been psychiatrically assessed and her treatment had commenced much earlier, it is likely that this death could have been avoided.
(v) There is an inferior system for the assessment and treatment of patients on the Medical Admissions Unit of patients suffering from mental illness in comparison with those who are physically ill . The Trust should therefore review this urgently and ensure that the systems are developed to provide for a faster system to rule out physical illness that might cause or contribute to mental disturbance and when this has been achieved to provide a prompt assessment, diagnosis and treatment for such patients in respect of their obvious mental illness.
” 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 Leeds Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly rule out physical illness contributing to mental disturbance
Wider context from the report “1. (i) There was a considerable delay of over 60 hours before a psychiatrist attended St James’s University Hospital to assess Mary Wanya. In fact the psychiatrist arrived 5 minutes after her fall had occurred and hence she never received a psychiatric assessment.
(ii) The Trust should review the system for obtaining urgent psychiatric assessments, particularly out of hours, with a view to speeding up and providing a more efficient service.
(iii) In view of the size and scale of the St James’s University site the Trust should consider having an on site resident psychiatrist to avoid the obvious delay in bringing psychiatrists from St Mary’s Hospital, which is some distance away and will exacerbate delay.
(iv) The Trust should consider making arrangements with the Mental Health Trust responsible for the Becklin Centre so that the Becklin Centre staff should be involved with such patients, particularly out of hours, to avoid delay and to provide earlier diagnosis and treatment. Had Mrs Wanya been transferred to the Becklin Centre and been psychiatrically assessed and her treatment had commenced much earlier, it is likely that this death could have been avoided.
(v) There is an inferior system for the assessment and treatment of patients on the Medical Admissions Unit of patients suffering from mental illness in comparison with those who are physically ill . The Trust should therefore review this urgently and ensure that the systems are developed to provide for a faster system to rule out physical illness that might cause or contribute to mental disturbance and when this has been achieved to provide a prompt assessment, diagnosis and treatment for such patients in respect of their obvious mental illness.
” 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