1 Aug 2025 Suzanne EDWARDS · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1 Unreliable access to patients' primary care records in Emergency Departments View source
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Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Suzanne EDWARDS · 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
Suzanne EDWARDS became unwell on 29 November 2024, was assessed by her GP and at Milton Keynes Hospital, admitted to Bedford Hospital for surgery to insert a kidney stent, and died there of sepsis on 1 December 2024. The principal concern was that emergency departments lacked reliable access to patients’ primary care records, and the inquest identified a failure to recognise signs of urinary tract obstruction, resulting in a lost opportunity to treat the condition before sepsis developed.
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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 Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Unreliable access to patients' primary care records in Emergency Departments
Wider context from the report “Emergency Departments at hospitals in this and surrounding jurisdictions do not have reliable access to patients' primary care records, including recent GP consultations, investigations or concerns. This means that clinicians are frequently treating acutely unwell patients without full access to their recent medical history , which can delay or misdirect diagnosis and undermine patient safety and continuity of care and lead to avoidable deaths.
Without access to a patients full records further lives may be put at risk.
” Open source report
6 Sep 2019 Millie Creasy · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 3 Failure to consider neuroprotective strategies after prolonged seizure View source Lack of prescriptive clinical treatment guidance for children presenting with prolonged seizure View source Failure to maintain neurological observation after prolonged seizure View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Millie Creasy · 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
Millie Creasy suffered a prolonged seizure at home on 31 July 2018, was discharged from hospital after limited neurological observations, and was readmitted after deteriorating. She subsequently suffered respiratory arrest caused by brain herniation from raised intracranial pressure, and brain stem death was confirmed on 5 August 2018. Concerns included the lack of continued neurological observations, the absence of consideration of neuroprotective strategies after a prolonged seizure, and whether earlier identification and treatment of raised intracranial pressure might have improved her chances of survival.
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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 Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consider neuroprotective strategies after prolonged seizure
Wider context from the report “(1) Millie was admitted to the Luton & Dunstable Hospital on 31 July 2018 at 14.42 hours having suffered a prolonged seizure of approximately 30 minutes which paramedics described as decorticate. She was subsequently discharged at 20.40 hours for with an appointment for review the following day (regular neurological observations had ceased after 2 hours);
(2) Whilst my factual findings recognised that any earlier treatment for raised ICP may not have altered the outcome, and that a diagnosis of raised ICP or the risk of raised ICP is a clinical one, I was informed that it was not possible for the Luton & Dunstable NHS Trust to be more prescriptive in terms of clinical treatment in cases where a child presents with a history of prolonged seizure and that, in any event, “the Trust did not have stronger evidence that a longer period of observation would help as neuro-observations will only detect the late situation when cerebral oedema has reached the point of coning/tonsillar herniation when intervention is often not effective. Additional interventions would only occur when the process is advanced enough for clinical detection and the outcome is poor”;
(3) During the Inquest, I heard evidence from ████████, Paediatric Intensivist, at St Mary’s Hospital, London. Both the Pathologist and ████████ agreed that an prolonged seizure can cause a hypoxic brain injury that may not become clinically apparent for hours or even days. ████████ also explained that if Millie’s condition had been identified at the stage of ‘peri-herniation’, she would have received neuroprotective procedures which would have improved her chances of survival; I have since been provided with a copy of the Imperial College Healthcare NHS Trust Guideline (Drafted by ████████): Neuroprotection for the patient on the Paediatric Intensive Care Unit. The scope of the guideline is said to be multi-protection team working in any area of Paediatrics and states that: “Whenever a patient has suffered a neurological insult or is at risk of primary (cellular damage leading to cell death) or secondary neurological injury (further cellular and structural injury) neuroprotective strategies should be commenced. Clinical situations where this should be considered include the following:
Traumatic Brain Injury
Sepsis – prolonged hypotension
Sepsis – meningitis, encephalitis
Post-cardiac arrest
Any CNS insult – prolonged seizures
Metabolic derangements – sodium, glucose, ammonia
Liver failure – encephalopathy”;
(4) Although the evidence suggested Millie had suffered a prolonged seizure, there was no evidence to suggest the potential need for neuroprotective strategies was, in fact, considered by the Luton & Dunstable NHS Trust .
” 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 Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of prescriptive clinical treatment guidance for children presenting with prolonged seizure
Wider context from the report “(1) Millie was admitted to the Luton & Dunstable Hospital on 31 July 2018 at 14.42 hours having suffered a prolonged seizure of approximately 30 minutes which paramedics described as decorticate. She was subsequently discharged at 20.40 hours for with an appointment for review the following day (regular neurological observations had ceased after 2 hours);
(2) Whilst my factual findings recognised that any earlier treatment for raised ICP may not have altered the outcome, and that a diagnosis of raised ICP or the risk of raised ICP is a clinical one, I was informed that it was not possible for the Luton & Dunstable NHS Trust to be more prescriptive in terms of clinical treatment in cases where a child presents with a history of prolonged seizure and that, in any event, “the Trust did not have stronger evidence that a longer period of observation would help as neuro-observations will only detect the late situation when cerebral oedema has reached the point of coning/tonsillar herniation when intervention is often not effective. Additional interventions would only occur when the process is advanced enough for clinical detection and the outcome is poor”;
(3) During the Inquest, I heard evidence from ████████, Paediatric Intensivist, at St Mary’s Hospital, London. Both the Pathologist and ████████ agreed that an prolonged seizure can cause a hypoxic brain injury that may not become clinically apparent for hours or even days. ████████ also explained that if Millie’s condition had been identified at the stage of ‘peri-herniation’, she would have received neuroprotective procedures which would have improved her chances of survival; I have since been provided with a copy of the Imperial College Healthcare NHS Trust Guideline (Drafted by ████████): Neuroprotection for the patient on the Paediatric Intensive Care Unit. The scope of the guideline is said to be multi-protection team working in any area of Paediatrics and states that: “Whenever a patient has suffered a neurological insult or is at risk of primary (cellular damage leading to cell death) or secondary neurological injury (further cellular and structural injury) neuroprotective strategies should be commenced. Clinical situations where this should be considered include the following:
Traumatic Brain Injury
Sepsis – prolonged hypotension
Sepsis – meningitis, encephalitis
Post-cardiac arrest
Any CNS insult – prolonged seizures
Metabolic derangements – sodium, glucose, ammonia
Liver failure – encephalopathy”;
(4) Although the evidence suggested Millie had suffered a prolonged seizure, there was no evidence to suggest the potential need for neuroprotective strategies was, in fact, considered by the Luton & Dunstable NHS Trust.
” 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 Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain neurological observation after prolonged seizure
Wider context from the report “(1) Millie was admitted to the Luton & Dunstable Hospital on 31 July 2018 at 14.42 hours having suffered a prolonged seizure of approximately 30 minutes which paramedics described as decorticate. She was subsequently discharged at 20.40 hours for with an appointment for review the following day (regular neurological observations had ceased after 2 hours );
(2) Whilst my factual findings recognised that any earlier treatment for raised ICP may not have altered the outcome, and that a diagnosis of raised ICP or the risk of raised ICP is a clinical one, I was informed that it was not possible for the Luton & Dunstable NHS Trust to be more prescriptive in terms of clinical treatment in cases where a child presents with a history of prolonged seizure and that, in any event, “the Trust did not have stronger evidence that a longer period of observation would help as neuro-observations will only detect the late situation when cerebral oedema has reached the point of coning/tonsillar herniation when intervention is often not effective. Additional interventions would only occur when the process is advanced enough for clinical detection and the outcome is poor”;
(3) During the Inquest, I heard evidence from ████████, Paediatric Intensivist, at St Mary’s Hospital, London. Both the Pathologist and ████████ agreed that an prolonged seizure can cause a hypoxic brain injury that may not become clinically apparent for hours or even days. ████████ also explained that if Millie’s condition had been identified at the stage of ‘peri-herniation’, she would have received neuroprotective procedures which would have improved her chances of survival; I have since been provided with a copy of the Imperial College Healthcare NHS Trust Guideline (Drafted by ████████): Neuroprotection for the patient on the Paediatric Intensive Care Unit. The scope of the guideline is said to be multi-protection team working in any area of Paediatrics and states that: “Whenever a patient has suffered a neurological insult or is at risk of primary (cellular damage leading to cell death) or secondary neurological injury (further cellular and structural injury) neuroprotective strategies should be commenced. Clinical situations where this should be considered include the following:
Traumatic Brain Injury
Sepsis – prolonged hypotension
Sepsis – meningitis, encephalitis
Post-cardiac arrest
Any CNS insult – prolonged seizures
Metabolic derangements – sodium, glucose, ammonia
Liver failure – encephalopathy”;
(4) Although the evidence suggested Millie had suffered a prolonged seizure, there was no evidence to suggest the potential need for neuroprotective strategies was, in fact, considered by the Luton & Dunstable NHS Trust.
” Open source report
29 Mar 2018 Matthew Luke FAULKNER · Prevention of Future Deaths report Hertfordshire
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Concerns raised 3 Insufficient EEAS resources for demand View source Delays in handover to hospital View source Unsustainable public demand on the EEAS View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Matthew Luke FAULKNER · 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
Matthew Faulkner was found hanging from his bathroom door handle on the evening of 30 May 2017 and was confirmed dead at 21:57. The report raised concerns about the almost five-hour delay between the emergency call and ambulance attendance, as well as ambulance service demand exceeding available resources and delays handing patients over to 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 Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient EEAS resources for demand
Wider context from the report “(1) At the time of this incident, demand on the EEAS far outstripped the resources available to them .
(2) That the current position regarding demand outstripping available resources is not significantly different to that in May 2017 .
” 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 Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in handover to hospital
Wider context from the report “(4) That there are still significant delays on hand-over to hospital , exacerbating the lack of Ambulances being available to answer emergency calls.
” 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 Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Unsustainable public demand on the EEAS
Wider context from the report “(3) That the demands placed on the EEAS by the public are not sustainable . With, in the region of, only 60% of ambulance attendances resulting in admission to hospital for urgent care.
” 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 Board patients on wards by transferring them before beds become available, temporarily increasing ward capacity.
Verbatim wording from the response “We will transfer patients to wards where beds will shortly become available even if the space has not yet become” Source location 2018-0097-Response-by-Luton-Dunstable-University-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 Transfer existing emergency-department patients into hospital and assessment beds to prioritise cubicle space for arriving ambulance patients.
Verbatim wording from the response “It is the Trust’s firm belief that it is not safe practice to cohort ambulance patients as these are often the most vulnerable patients in ED having not yet been assessed. Therefore there are a number of other steps taken to assess existing patients and their need for a trolley whilst flexing both capacity within and nearby the department by using it in a different way as well as cohorting stable patients awaiting inpatient beds and boarding patients on inpatient wards. Therefore, at the L&D we prioritise cubicle space for new patients coming in from ambulances, and will transfer existing patients into hospital and assessment beds to accommodate this. We will open further contingency areas as necessary in order to proactively create space rather than react to deficiencies in it.” Source location 2018-0097-Response-by-Luton-Dunstable-University-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 Open further contingency areas as necessary to proactively create emergency-department capacity and reduce ambulance offload delays.
Verbatim wording from the response “It is the Trust’s firm belief that it is not safe practice to cohort ambulance patients as these are often the most vulnerable patients in ED having not yet been assessed. Therefore there are a number of other steps taken to assess existing patients and their need for a trolley whilst flexing both capacity within and nearby the department by using it in a different way as well as cohorting stable patients awaiting inpatient beds and boarding patients on inpatient wards. Therefore, at the L&D we prioritise cubicle space for new patients coming in from ambulances, and will transfer existing patients into hospital and assessment beds to accommodate this. We will open further contingency areas as necessary in order to proactively create space rather than react to deficiencies in it.” Source location 2018-0097-Response-by-Luton-Dunstable-University-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 Maintain contingency capacity by operating an additional ward and surgical outlier bays to mitigate emergency-department overcrowding and ambulance offload delays.
Verbatim wording from the response “On 30th May 2017, between 17:00 and 22:00 hours, 19 ambulances were delayed at the Luton and Dunstable Hospital. This consisted of 11 ambulances under 30 mins and 8 ambulances under 60 mins, amounting to 368 minutes in total. As it was the Tuesday post Bank Holiday, ED attendances were expected to be high and indeed 326 patients attended across the 24 hour period, higher than the rolling 30 day average of 296. 88 patients arrived by ambulance which is within normal daily expectations. The bed reports from that day indicates high numbers of patients in the department - at 4pm there were 67 patients in ED and 8pm, 58 patients, which would have caused some overcrowding within the department. Similarly due to the Bank holiday weekend, discharges were reduced compared with normal; the Trust already had taken steps to mitigate this by using one contingency ward of” Source location 2018-0097-Response-by-Luton-Dunstable-University-Hospital
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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 Existing ambulance-handover monitoring, escalation and capacity-management arrangements are considered adequate to address delays.
Verbatim wording from the response “Generally the L&D’s performance regarding ambulance handovers is considered to be very reasonable. We have long adopted this metric as one of our triggers for patient flow escalation, which is monitored carefully throughout a 24 hour period. We always act upon handover delays if it becomes apparent that flow has reduced, and this is contained within our four times daily bed report. The escalation process involves input from an executive director and one of the medical directors. Whilst there is always room for improvement, the Weekly Sitrep ending 4th June 2017 shows that we had no ambulances waiting over 60 mins through the whole week. Attached to this letter is the East of England Ambulance service data for the period in question, showing the position of the L&D and all other trusts served by EEAST.” Source location 2018-0097-Response-by-Luton-Dunstable-University-Hospital
Open published response
26 Jan 2017 Albie Henderson Marlow · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1 Failure to respect mothers' requests for Caesarean Section delivery View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Albie Henderson Marlow · 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
Albie Henderson Marlow was delivered by Category 2 Caesarean Section at 37 weeks’ gestation and was recorded as stillborn, although the family stated that he cried. The principal concern was that the mother’s requests for Caesarean delivery during labour were not respected, with the report stating that this placed babies’ lives at risk.
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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 Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to respect mothers' requests for Caesarean Section delivery
Wider context from the report “During the course of the Inquiry into the death of Baby Albie I heard that throughout labour his mother had asked for, and indeed, "begged" for a Caesarean Section delivery and her wish was not granted. She expressed concern that the delivery was following the same pattern as an earlier pregnancy and it had resulted in a delivery by emergency C Section. It was apparent that if baby Albie had been delivered when mother requested a C section he would have survived.
My concern is that mothers requesting delivery by Caesarean Section are not having their wishes respected and this is putting babies' lives at risk.
” Open source report
15 Dec 2016 Jean Marjorie McHALE · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 2 Failure to appropriately treat pressure ulcers in elderly people in the community View source Insufficient Tissue Viability Nurse staffing in community and hospital settings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Jean Marjorie McHALE · 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
Jean Marjorie McHALE was admitted to hospital in July 2016 with confusion, fever, poor general health and two Grade 4 pressure sores. The inquest concluded that she died from sepsis from infected pressure ulcers. Concerns included inadequate treatment of pressure ulcers, insufficient Tissue Viability Nurse provision, and the need for an urgent review.
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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 Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately treat pressure ulcers in elderly people in the community
Wider context from the report “(1) That if pressure ulcers are not treated appropriately to the elderly in the community will suffer, develop Osteomyelitis leading to Sepsis and 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 Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient Tissue Viability Nurse staffing in community and hospital settings
Wider context from the report “(2) That there are not enough Tissue Viability Nurses working in the community or in the hospital to meet the needs of the patients
” Open source report
2 Jun 2014 Essa Shah · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1 Failure to provide co-sleeping danger literature for discharged new mothers in languages other than English View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Essa Shah · 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
Essa Shah, aged eight weeks, went to sleep in the same bed as his mother following a feed and was later found unresponsive. The report raised concern that hospital literature about the dangers of co-sleeping was available only in English.
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 Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide co-sleeping danger literature for discharged new mothers in languages other than English
Wider context from the report “1. That the literature, setting out the dangers of co-sleeping which the hospital hand to new mothers being discharged, is only available in the English Language .
” Open source report
2 Jun 2014 Aimee Sarah VARNEY · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1 Failure to follow NICE referral guidelines for patients with suspected epilepsy to a Specialist Tertiary Centre View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Aimee Sarah VARNEY · 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
Aimee Sarah VARNEY died following a seizure from Sudden Unexpected Death in Epilepsy at her home address. The report identifies a concern that NICE guidance on referring patients with suspected epilepsy to a Specialist Tertiary Centre was not followed, and states that this represented a lost opportunity to diagnose and further treat her condition.
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 Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to follow NICE referral guidelines for patients with suspected epilepsy to a Specialist Tertiary Centre
Wider context from the report “1. That the NICE Guidelines for referring a patient with suspected epilepsy to a Specialist Tertiary Centre were not followed .
” Open source report
16 Apr 2014 Sari Marlene KEEN · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 3 Lack of sufficient staffing for patient caseloads View source Failure of staff to recognise an un-recordable blood pressure as a medical emergency requiring a crash call View source Failure to escalate care when overwhelmed View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sari Marlene KEEN · 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
Sari Marlene KEEN underwent surgery to remove colon tumours on 23 October 2013, developed a faecal anastomotic leak causing peritonitis and shock, and died following cardiac arrest on 24 October 2013. The substantive concerns were insufficient staffing and failures to recognise deterioration, escalate care, and call the Hospital Crash Team when her blood pressure became unrecordable.
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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 Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient staffing for patient caseloads
Wider context from the report “(1) The first matter of concern was that three witnesses who gave evidence, two Senior Nurses and one Doctor, told me that on the night that Sara died there were insufficient members of staff available to deal with the caseload of patients and this was not unusual . They felt overwhelmed and yet unable to escalate the 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 Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to recognise an un-recordable blood pressure as a medical emergency requiring a crash call
Wider context from the report “(2) It was apparent that many Senior and Junior Members of Staff were not aware that an ‘un-recordable blood pressure’ was a ‘medical emergency’ and should have resulted in a crash call going out for immediate resuscitation . Perhaps the Protocols for the Crash Team need to be reviewed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Luton and Dunstable University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate care when overwhelmed
Wider context from the report “(1) The first matter of concern was that three witnesses who gave evidence, two Senior Nurses and one Doctor, told me that on the night that Sara died there were insufficient members of staff available to deal with the caseload of patients and this was not unusual. They felt overwhelmed and yet unable to escalate the care .
” 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